Columbia  SSnitJem'tp 

College  of  ^ijpjsicians;  anb  ^urgeong 


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A 


CLINICAL    HISTORY 


MEDICAL  AND  SURGICAL  DISEASES 


WOMEN. 


BY 


ROBERT    BARNES,    M.  D.,   Lond., 

FELLOW  AND  LUMLEIAN  LECTURER  (1873)  ROYAL  COLLEGE  OF  PHYSICIANS  ;   EXAMINER  IN 

OBSTETRICS  AND    THE    DISEASES  OF    WOMEN  AT    THE    UNIVERSITY  OF    LONDQN 

AND    THE    ROYAL    COLLEGE    OP    SURGEONS;     OBSTETRIC    PHYSICIAN 

AND  LECTURER  ON  OBSTETRICS    AND  THE  DISEASES  OF 

WOMEN  TO  ST.  THOMAS'S  HOSPITAL. 


WITH  ONE  HUNDRED  AND  SIXTY-NINE  ILLUSTRATIONS. 


PHILADELPHIA: 

H   E   N   K   Y      C.      LEA. 

1874. 


SHERMAN    &    CO.,    PRINTERS, 
PHILADELPHIA. 


1;^ 


io( 


CD 

to 
CO 


Dear  McClintock: 

i  beg  of  you  to  accept  the  dedication  of  this  book, 
i  offer  it  in  geateful  acknowledgment  of  the  services 
rendered  to  the  department  op  medicine  of  -which  it 
treats  by  the  dublin  school,  whose  spirit  op  clinical 
observation  and  faithfulness  in  record  you  so  eminently 
represent,  op  the  honor  conferred  upon  me  by  the 
Dublin  Obstetrical  Society  by  electing  me  an  Honorary 
Member,  and  in  testimony  of  a  friendship  begun  in  Paris 
IN  our  student-days. 

Believe  me  yours  ever, 

EGBERT  BARNES. 

To  Alfred  H.  McClintock,  M.D., 

Honorary  President  of  the  Dublin  Obstetrical  Society,  &c. 


PREFACE. 


The  design  of  this  work  is  to  give  such  a  description  of  the  medi- 
cal and  surgical  diseases  of  women  as  will  assist  the  medical  practitioner 
in  their  diagnosis  and  treatment.  In  our  systematic  treatises  on  medi- 
cine and  surgery,  and  even  in  those  on  obstetrics  proper,  these  diseases 
are  for  the  greatest  part  either  ignored,  or  imperfectly  appreciated  and 
described.  Hence,  in  all  countries,  the  want  of  works  devoted  to  this 
branch  of  the  healing  art  has  been  felt.  To  a  great  extent  this  want 
has  been  successfully  met  by  authors  of  the  highest  reputation,  in 
France,  Germany,  America,  and  Great  Britain.  The  subject  is  wide 
and  important,  not  only  in  its  direct  application  to  the  relief  of  the 
special  diseases  it  embraces,  but  also  in  its  endless  and  interesting  rela- 
tions to  the  physiological  and  pathological  history  of  women.  In  the 
woman  the  reproductive  organs  exert  a  vastly  greater  influence  than 
they  do  in  the  man.  The  reactions  in  health  and  disease  between 
these  organs  and  the  rest  of  the  economy  are  multiform  and  incessant. 
The  physician  who  neglects  the  study  of  the  pelvic  diseases  in  women 
is  constantly  in  danger  of  overlooking  the  efficient  cause,  or  a  serious 
complication,  of  the  more  obvious  disorder  which  he  undertakes  to 
treat.  He  cannot  possibly  understand  many  of  the  disorders  of  the 
organs  of  assimilation,  of  respiration,  of  circulation,  and  especially  of 
the  nervous  system,  without  a  careful  investigation  of  the  condition  of 
the  reproductive  organs.  It  is  here  that  lies  concealed  the  missing  link 
in  his  chain  of  reasoning,  the  want  of  which  will  frequently  vitiate  all 
his  deductions,  and  thwart  all  his  efforts  in  treatment. 

To  some  physicians  of  the  class  referred  to,  the  bulk  of  this  volume 
may  seem  excessive.     I  would  suggest  the  reflection  that  this  apparent 


VI  PREFACE. 

excess  may  represent  the  extent  of  their  neglect.  My  own  fear,  which 
I  have  no  doubt  -will  be  shared  by  those  most  competent  to  judge,  is 
that  many  things  of  importance  are  inadequately  discussed.  In  a  sub- 
ject of  comparatively  recent  inquiry,  necessarily,  to  some  extent,  un- 
settled and  open  to  controversy,  a  fuller  statement  of  fundamental 
facts,  and  more  argumentative  discussion  are  called  for,  than  are 
necessary  in  the  exposition  of  the  more  generally  cultivated  depart- 
ments of  medicine. 

In  the  preparation  of  this  work,  although  not,  I  trust,  unmindful  of 
the  published  works  of  others,  I  have  drawn  greatly  from  my  own  ex- 
perience. I  have  endeavored  to  bring  into  the  circle  of  gynaecological 
literature  new  illustrations.  With  this  view  I  have  explored  the  rich 
mines  of  pathological  material  in  the  museums  of  the  College  of  Sur- 
geons and  of  the  London  hospitals.  I  am  anxious  to  take  this  oppor- 
tunity of  acknowledging  the  courteous,  even  warm  assistance,  given  to 
my  artists  and  to  myself  by  the  curators  and  other  officials  of  these 
museums.  To  my  friend  Dr.  McClintock  T  am  indebted  for  permis- 
sion to  use  two  illustrations  from  his  admirable  clinical  work  on  the 
"Diseases  of  Women."  I  have  also  to  express  my  thanks  to  Messrs. 
William  Garton,  formerly  Resident  Accoucheur,  A.  S.  L.  JSTewington, 
Ernest  Carr  Jackson,  and  Fancourt  Barnes,  lately  my  clinical  clerks 
at  St.  Thomas's,  for  valuable  assistance  in  the  labor  of  compiling  the 
indexes. 

Robert  Barnes. 

31  Grosvenor  Street,  London, 
November,  1873. 


CONTENTS. 


Introductory, 


PAGE 

.     17 


CHAPTEK  I. 

THE  GENITAL  OKGANS. 
Ovaries;  Corpus  Luteum, 


CHAPTER  II. 

The  Fallopian  Tubes,  .         .         .      ,    • 

CHAPTER  HI. 

The  Shape  of  the  Cavities  of  the  Uterus,    . 

CHAPTER  IV. 


19 


29 


.     45 


Structure  of  the  Uterus, 


CHAPTER  V. 


The  Vagina, 


CHAPTER  VI. 


CHAPTER  VII. 

The  Significance  of  Leucorrhcea, 


48 


56 


Conditions  Indicating  Necessity  for  Examination  ;  Disorder  of  Function  ;  Dis- 
tant and  Constitutional  Reactions  ;  the  Subjective  Signs  of  Local  Disease 
Indicate  Appeal  to  Objective  Signs;  Comparison  of  Study  of  Disease  of 
Pelvic  Organs  to  that  of  Skin  and  Eye  ;  Disturbance  of  Functions  of 
Ovaries,  Uterus,  and  Vagina;  Amenorrhoea,  Real  and  Occult;  Menor- 
rhagia ;  DysmenorrhcBa  ;  Dyspareunia ;  Retention  of  Urine  ;  Sterility  ; 
Abortion;  Discharges,  Sanguineous,  Mucous,  Purulent,  Albuminous, 
Watery,  Fleshy,  Membranous  ;  Pain,  Lumbo-Dorsal,  Inguinal,  Pelvic,    .     65 


73 


Vlll  CONTENTS. 


CHAPTEK  VIII.  / 

PAGE 

Discharges  of  Air,      ............       82 


CHAPTER  IX. 

The  Watery  Discharges,    ...........       83 

CHAPTER  X. 

The  Purulent  Discharges,  ...........       87 

CHAPTER  XL 

The  Significance  of  Hemorrhagic  Discharges, 88 

CHAPTER  XII. 

The  Significance  of  Pain, 98 

CHAPTER  XIII. 

The  Significance  of  "  Dyspareunia,"  including  "Vaginismus,"       .         .         .     102 

CHAPTER  XIV. 

The  Significance  of  Sterility, 107 

CHAPTER  XV. 

The  Instruments  Serving  for  Diagnosis  and  Treatment, 115 

CHAPTER  XVI. 

The  Diagnosis  of  Diseases  of  the  Pelvic  Organs  ;  the  Touch  ;  the  Sound  ;  the 

Speculum,    .............     132 

CHAPTER  XVII. 

THE  PATHOLOGY  OF  THE  OVARIES. 
The  History  of  Menstruation  and  its  Disorders, 146 

CHAPTER  XVIII. 

Disordered  Menstruation  (Paramenia,  W.  Parr)  ;  Amenorrhcea,     .         .         .     163 

CHAPTER  XIX. 

Amenorrhoea  from  Retention  ;  Retained  Menses  from  Occlusion  or  Atresia  of 
the  Uterus,  Vagina,  or  Vulva,  or  from  Imperforate  Hymen;  Occult  Men- 
struation ;  Hajmatomelra,  ..........     175 


CONTENTS.  IX 

^  CHAPTER  XX. 

PAGE 

Dysmenorrhoea ;    Neuralgic;    Congestive;    from   Obstructed  Excretion;    In- 
flammatory, ............     192 

CHAPTER  XXI. 

Ovarian  Dysmenorrhoea  ;  Dysootocia  ;  Oophoria  (Hysteria) ;   Tubal  Dysmen- 
orrhoea,         217 

CHAPTER  XXII. 

Inflammatory  Dysmenorrhoea  ;  Dysmenorrhoea  Membranacea,         .         .         .     225 

CHAPTER  XXIII. 

The  Menstrual  Irregularities  of  the  Climacteric  Epoch, 234 

CHAPTER  XXIV. 

The  Eelations  of  Menstruation  to  various  Diseases;  the  Influences  of  Ovula- 
tion and  Menstruation  in  Evoking  Morbid  Influences,      ....     242 

CHAPTER  XXV. 

The  Disorders  of  Senility  or  Decrepitude,  .         .         .         .         .         .         .     249 

f 

CHAPTER  XXVI. 

Ovary:  Absence  of  Abnormal  Conditions  of ;  Displacement;  Hernia,     .         .     252 

CHAPTER  XXVII. 

Ovary:  Hyperemia,  Hemorrhage,  and  Anomalies  of  the  Corpus  Luteum,        .     255 

CHAPTER  XXVIII. 

Ovary  :  Tubercle ;  Cancer  ;  Solid  Tumors, 268 

CHAPTER  XXIX. 

Ovarian  Cystic  Tumors  :  their  Nature — Simple;  Multiple;  Proliferous;  Cysto- 

Sarcomatous  ;  Tubo-Ovarian — Contents  of  Ovarian  Cysts  :  Dermoid  Cj'sts,     277 

CHAPTER  XXX. 

Cutaneous  Proliferous  Cysts  ;  or.  Dermoid  Cysts  of  the  Ovary,         .         .         .     290 

CHAPTER  XXXI. 

Natural  Course  and  Terminations  of  Ovarian  Tumors,     .....     294 


X  CONTENTS. 

CHAPTER  XXXII. 

PAGE 

Diagnosis  of  Ovarian  TumorS; 305 

CHAPTER  XXXIII. 

Treatment  of  Ovarian  Cystic  Disease  ;  Medicinal  ;  Tapping  by  Vagina,  and  by 

Abdomen, 325 

CHAPTER  XXXIV. 

The  Fallopian  Tubes;  Absence  of ;  Separation  ;  Cysts;  Carcinoma;  Tubercle;     ; 
Fibroid  Tumors;  Hypertrophy;   Elongation;  Dilatation;  Inflammation 
(Salpingitis);  Catarrh;    Haematoma;    Occlusion;  Cystic  Enlargements; 
Dropsy, 350 

CHAPTER  XXXV. 

The  Broad  Ligaments;  Dropsy;  Inflammation;    Phlegmasia  Dolens;  Phle- 

bolithes  ;  Fibroid  Tumors, 360 

CHAPTER  XXXVI. 

Extra-uterine  Gestation  ;  Tubal ;  Ovarian  ;   Tubo-Ovarian  ;  Abdominal ;  In- 
terstitial ;  One-Horned  Uterine  Gestation, 362 

CHAPTER  XXXVII. 

Special  Pathology  of  the  Uterus  ;  Abnormal  Conditions  ;  Developmental  Faults,    395 

CHAPTER  XXXVIII. 

General  Observations  on  Uterine  Pathology ;  Eftects  of  Labor  and  Lactation  ; 

Involution  in  Defect  and  Excess, 405 

CHAPTER  XXXIX. 

Conditions  marked  by  Altered  Vascularity  or  Blood-Supply;  Fluxion;  Hyper- 

temia;  Congestion;  Inflammation,     ........     423 

CHAPTER  XL. 

Metritis  ;  Endometritis  ;  Follicular  Excoriations  ;  Aphthous  Eruptions  ;  Vari- 
cose Ulcer,  433 

CHAPTER  XLI. 

Pelvic  Cellulitis  (Parametritis) ;  Pelvic  Peritonitis  (Perimetritis)  ;  Perimetric 

Inflammation  (Peri-Uterine  Inflammation)  ;  Metro-Peritonitis,        .         .     479 

CHAPTER  XLII. 

Perimetric  Hasmatocele  ;    Retro-Uterine  Htematocele  ;    Pelvic  Hsematocele  ; 

Blood-Effusions  in  the  Neighborhood  of  the  Uterus,  ....     603 


CONTENTS.  XI 

CHAPTER  XLIII. 

PAGE 

Displacements  of  the  Uterus;  Definhion ;  Varieties  of:  Prolapsus  Described; 

Hypertrophy  of  the  Vaginal-Portion, 533 

CHAPTER  XLIV. 

DISPLACEMENTS  OF  THE  UTEEUS  {continued): 

Oblique  or  Lateral  Inclinations ;  Elevation ;  Depression ;  Elongation  by 
Stretching  and  Pressure  ;  Dislocations  of  Uterus  by  External  Pressure ; 
Versions  and  Flexions  ;  Anteversion  ;  Anteflexion,  .....     577 

CHAPTER  XLV. 

Ketroversion  ;  Ketroflexion,       ..........     595 

CHAPTER  XLVI. 

Inversion  of  the  Uterus  ;  Definition  ;  Acute  and  Chronic ;  Causes,  in  the 
Parturient  and  Non-Pregnant  Uterus;  Symptoms,  Course,  and  Termina- 
tions ;  Prognosis;  Diagnosis;  Treatment,  .         .         .         .         .         .615 

CHAPTER   XLVII. 

Tumors  of  the  Uterus  ;  Malignant  and  Non-Malignant ;  Fibroid  or  Myoma  ; 
Description  of  Fibroids,  their  Natural  History,  Rise,  Progress,  and  Ter- 
minations ;  Varieties  of  Fibroid  Tumors  ;  the  Difi^use  Tumor  ;  the  Fibro- 
Cj'stic  ;  the  Recurrent  Fibroid  ;  the  Erectile  Tumor  of  Carswell ;  the  De- 
velopment and  Decay  of  Fibroids ;  Effects  of  Fibroids  upon  the  Uterus 
and  Surrounding  Organs  and  System  Generally ;  the  Symptoms  and 
Diagnosis  ;  the  Treatment,  .........     639 

CHAPTER  XLVIII. 

POLYPUS  UTERI. 

Definition;  Forms  of;  Fibroid  or  Myoma;  Glandular  or  Mucous;  Hyper- 
trophic ;  Vascular  ;  Placental ;  Fibrinous  ;  History  of  Fibroid  ;  Fibror 
Cystic  Variety  ;  Synxptoms  ;  Terminations  ;  Intra-Uterine  and  Extra- 
Uterine  Polypi  ;  Diagnosis  ;  Treatment ;  Slow  Strangulation,  Dangers 
of;  Torsion,  Crushing,  and  Excision  by  Scissors;  Removal  by  Polyp- 
tome,  Eeraseur,  Galvanic  Wire-Cautery, 676 

CHAPTER  XLIX. 

Tubercle  of  the  Uterus, 695 

CHAPTER   L. 

Cancer  ;  Definition ;  Degrees  of  Malignancy ;  its  Local  Origin ;  Hereditary 
Transmission  ;  its  Frequency  ;  Causes  ;  Forms  of :  Medullary  ;  Epitheli- 
oma ;  Sarcoma ;  Scirrhous ;  Myxoma.  Cancer  and  Pregnancy.  The 
Course  and  Terminations  of  Cancer  ;  Diagnosis  ;  Prognosis.     Treatment : 


XU  CONTENTS. 


PAGE 

Question  of  Curability  ;  Total  Extirpation  of  Uterus  ;  Amputation  of 
Yaginal-Portion,  Selection  of  Cases  for  ;  the  Operation  ;  Cautery,  Actual 
and  Potential.  Treatment  of  Cancer  of  Body  of  the  Uterus.  Palliative 
Treatment  ;  Local  and  Constitutional,        .         .         .         .         .         .         .     701 


CHAPTER    LI. 

THE  DISEASES  OE  THE  VAGINA. 

Colpitis  ;  Simple,  Infectious,  Acute,  Chronic  ;  Displacements  ;  Wounds  ;  Di- 
latation ;  Atrophy  ;  Sloughing  ;  Cicatrices  ;  Vesico-Vaginal  and  Hecto- 
Vaginal  Eistulse ;  Euptured  Perineum  ;  New  Eormations  ;  Fibrous  Tu- 
mors ;  Sarcomata  ;  Cystic  Tumors  ;  Hsematoma  ;    Calculi ;   Cancer,  .     739 

CHAPTER   LII. 

THE  DISEASES  OF  THE  VULVA. 

Inflammation  :  General  or  Partial  ;  of  the  Vulvo-Vaginal  Glands;  Abscesses  ; 
Ulcerations  ;  Sloughs  ;  Hsematoma  ;  Varicosity  ;  Pruritus  ;  Hypertrophy 
of  Labia  and  Clitoris;  "  Endermoptosis  ;"  Neuromata;  Cysts;  Syphil- 
itic Warty  Excrescences;  Lupus;  Cancer;  Melanosis;  Vascular  Ex- 
crescence of  the^  Meatus  Urinarius  ;  Fissure  of  the  Vulva.  Coccygo- 
dynia, 754 


INDEX, 769 


LIST  OF  WOOD  ENGRAVINGS. 


PIG. 
1. 

2. 
3. 
4. 
5. 


10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
18. 
19. 
20. 
21. 
22. 
23. 
24. 
25. 
26. 

27. 
28. 
29. 
80. 
31. 
32. 
33. 
34. 
35. 
36. 
37. 
38, 


Tubes  (A. 


Fan- 


Genital  Organs,  in  situ  (Savage),  .... 

Adult  Paroi^arium,  Ovary,  and  Fallopian  Tube  (Kobelt), 
Eight  Fallopian  Tube  laid  open  (Richard), 
Ovary  enlarged  under  Menstrual  Nisus  (Eaciborski), 
Menstrual  Corpus  Luteum  and  Ovary  (Eaciborski),  . 
Bulb  of  Ovary  (Savage), 
Ovary  in  old  age,         .... 
Longitudinal  Section  of  Pelvis  (Breisky) 
Uterus  and  Appendages  of  an  Infant  (A.  Farre 
Eegional  Divisions  of  the  Uterus  (A.  Farre), 
Vertical  Section  of  the  Uterus  (A.  Farre), 
Virgin  Os  Uteri  and  Vaginal-Portion  (A.  Farre), 
Os  Uteri  in  old  age,      ..... 
The  Uterus  in  old  age  (A.  Farre), 
Thinning  of  the  Walls  in  old  age  (A.  Farre), 
Cervix  laid  open  (Hassall  and  Tyler  Smith), 
Section  of  Uterus,  above  entrance  of  Fallopian 
Section  through  centre  of  cavity  of  Uterus, 
Section  through  centre  of  Cervical  Canal 
Uterus  of  Virgin,  set.  17,    . 
Multiparous  Uterus,  set.  25-30,    . 
Multiparous  Uterus,  set.  42, 
Multiparous  Uterus,  set.  35, 

Villi  of  Os  Uteri,  Epithelium  removed  (Tyler  S 
Extremities  of  Villi  of  Os  Uteri  (Tyler  Smith 
Villi  of  Os  Uteri,  covered  with  looped  Bloodvessels  (Tyler 
Hassall), 

Mucous  Discharge  from  healthy  Cervix  Uteri  (Tyler  Smith  and  Has 

Cervical  Leucorrhoea  (Tyler  Smith  and  Hassall) 

Epithelium  from  Vaginal  Leucorrhoea  (Tyler  Smith  and  Hassall) 

Fergusson's  Speculum,         ..... 

Henry  Bennet's  Speculum  modified  (Barnes),     . 

Cusco's  Speculum,        ...... 

Sinis's  Speculum,  ...... 

Barnes's  Modification  of  JSfeugebauer's  Speculum 

Simpson's  Uterine  Sound,    ...         .         .         . 

Barnes's  Whalebone  Sound,  .... 

Kiichenmeister's  Metrotome  Scissors, . 

Simpson's  Metrotome,  ..... 


mith  and  Hass 
and  Hassall), 


mith 


;all), 


PAGE 

19 
21 
21 
23 
24 
26 
28 
33 
39 
40 
40 
42 
42 
42 
43 
43 
45 
46 
46 
46 
46 
47 
47 
52 
52 

53 

71 

71 

72 

119 

119 

120 

120 

121 

124 

124 

124 

126 


XIV  LIST    OF     WOOD     ENGRAVINGS. 

MG.  PAGE 

89.  Sims's  Tenaculum  Hook,      ,         . " 126 

40.  Improved  Wire  Ecraseur,    .         .         .         .         .         .         .         .         .         .  127 

41.  Barnes's   Instrument   for  introducing  Laminaria  or  Sponge-Tents  into 

Uterus,     . 127 

42.  Barnes's  Nitrate  of  Silver  Cautery,    ........  129 

43.  Barnes's  Tube  for  depositing  Sticks  of  Sulphate  of  Zinc  in  Uterus,  .         .  129 

44.  Barnes's  Uterine  Ointment  Positor,     .         .         .         .         .         .         .         .129 

45.  Higginson's  Vaginal  Syringe,      .........  131 

46.  Barnes's  Speculum  for  application  of  Medicated  Cotton-Wool  in  Vagina,  131 

47.  48.  Skeleton  Diagrams  for  recording  Alterations  of  Size,  Position,  and 

Eelations  of  Pelvic  and  Abdominal  Organs, 133,  134 

49.  Diagnosis  of  early  Pregnancy,    .........  139 

50.  Showing  Pteversal  of  Sound  in  Vtero, 141 

51.  Dilated  Utei-us  and  Vagina  (St.  George's  Museum), 179 

52.  Complete  Occlusion  of  Vulva  (Kadcliffe  Museum),     .....  180 

53.  Atresia  of  Vagina, 187 

54.  Conical  Vaginal-Portion, .  202 

55.  Conical  Vaginal-Portion, 202 

56.  Conical  Vaginal-Portion,     ..........  202 

57.  Common  form  of  narrow  Os  Uteri  in  Dysmenorrhoea  and  Sterility, .         .  202 

58.  Section  of  Conical  Cervix  with  small  Os  Externum, 203 

59.  60.  Sections  of  Uterus  made  at  Os  Internum, 207 

61.  Eepresenting  the  Action  of  two-bladed  Metrotomes, 210 

62.  Action  of  Kiichenmeister's  Scissors, 216 

63.  Exfoliated  Mucous  Membrane  of  Vagina,  . 231 

64.  Uterine  Mucous  Membrane  shed  entire,      .......  231 

65.  Blood  Coagulum  in  a  Cyst  of  Ovai-y,  ........  256 

66.  Fibrous  Tumor  of  Ovary, 257 

67.  Early  Stage  of  Cystic  Disease, 278 

68.  Surface  of  Ovary,  Prominences  of  Dilated  Graafian  Follicles,   .         .         .  278 

69.  Incipient  Cystic  Enlargement  of  Graafian  Follicles, 279 

70.  Fibrous  Stroma  of  Compound  Cystic  Tumor  of  Ovary  (H.  Arnott),          .  282 

71.  Epithelial  Lining  of  a  Compound  Ovarian  Cyst  (H.  Arnott),    .         .         .283 

72.  Section  of  Ovarian  Tumor  showing  Alveolar  Structure,     ....  284 

73.  Ovaries  aifected  with  Proliferating  Malignant  Disease,      ....  285 

74.  Tubo-Ovarian  Cyst  (Carswell), "      .  286 

75.  Dermoid  Cyst  of  Ovary, 291 

76.  Ovarian  Tumor  and  Pregnane}',  .         .         .         .         .         .         .         .311 

77.  78,  79.  Diagrams:  Diagnosis  of  Ascites  and  Ovarian  Dropsy,    .         .      317,  318 

80.  Inflammation  of  Fallopian  Tubes, 354 

81.  Dropsy  of  Fallopian  Tube, 358 

82.  Gestation  in  Fallopian  Tube, 366 

83.  Gestation  in  Eudimentary  Horn  of  Uterus, 368  , 

84.  Tubo-Uterine  Gestation, 389 

85.  Uterus  strongly  developed  to  right, 396 

86.  Double  or  Bicornute  Uterus, 397 

87.  Bicornute  Uterus, 398 

88.  Bicornute  Uterus,  Septum  dividing  Cavity, 399 

89.  Double  Uterus  and  Vagina, 400 

90.  Transverse  Section  of  Vagina  of  preceding  Figure, 401 

91.  Atrophy  of  the  Uterus  and  Ovaries, 403 


LIST    OF    WOOD    ENGRAVINGS.  XV 

FIG.  PAGE 

92.  Stenosis  ;  Atresia  ;  Dilatation  of  Uterus,  ..         .         .         .         .         .         .  404 

93.  Kepresenting  Bulk  of  Uterus  arrested  in  its  Involution  after  Pregnancy, 

and  also  the  Bulk  it  ought  to  attain  (Simpson),       .....  409 

94.  Congestion  of  Vaginal-Portion  of  Cervix  after  Labor,      ....  419 

95.  Showing  Loss  of  Epithelium,  leaving  Villi  of  Os  Uteri  bare  (Hassall),    .  420 

96.  Epithelial  Abrasion  after  Labor, 422 

97.  Marion  Sims's  Curette, 476 

98.  Eecamier's  Curette, 476 

99.  Collar  of  Hard  Inflammatory  Effusion  encircling  Cervix  Uteri,       .         .  498 

100.  Remains  of  a  Eetro-Uterine  Hfematocele  (Guy's),     .....  510 

101.  Eetro-Uterine  Haematocele  from  Diseased  Ovary,      .         .         .         .         .515 

102.  Eetro-Uterine  Hsematoeele,        ......•-.  517 

103.  Sectional  View  of  the  Parts, 518 

104.  Illustrating  Stages  of  Prolapse  of  Uterus,          ......  535 

105.  Complete  Procidentia  Uteri,       .........  536 

106.  Prolapsus  Uteri, 587 

107.  One  form  of  Hypertrophy  of  Vaginal-Portion  of  Cervix  Uteri,         .         .  540 

108.  Appearance  of  same  after  Complete  Cicatrization  from  Amputation  by 

the  Galvanic  Cautery,      .         .         .         .         .         .         .         .         .         .  541 

109.  Eversion  of  Mucous  Membrane  of  Cervix  Uteri, 542 

110.  Prolapse  of  Uterus,  with  Hypertrophic  Elongation  and  Complete  Ever- 

sion of  Vagina,         .         .      '  .         .         .         .         .         .         .         .         .  543 

111.  Hypertrophy  with  Procidentia  of  Vaginal-Portion  of  Cervix  Uteri,         .  544 

112.  Early  Stage  of  Hypertrophic  Elongation  of  Cervix  Uteri,         .         .         .  545 

113.  Advanced  Hypertrophic  Elongation  of  Cervix  Uteri,        ....  546 

114.  Hypertrophic  Elongation  of  both  Supra  and  Infra  Vaginal-Portions  of 

Cervix  Uteri  (King's  College),        ........  547 

115.  Great   Hypertrophic   Elongation   of  Supra  Vaginal-Portion  of  Cervix 

Uteri  (Bartholomew's), 549 

116.  Hypertrophic  Elongation  of  Uterus  (St.  Thomas's),           ....  550 
•  117.  The  Galvanic  Pessary, 564 

118  The  Cup-and-Stem  Pessary, 569 

119.  Diagram  illustrating  Versions  and  Flexions  of  Uterus,    ....  581 

120.  Thomas's  Anteversion  Pessary,           ........  587 

121.  Ditto  when  in  Use, 587 

122.  Thomas's  Anteversion  Pessary  in  Action,          .         .         .         .         .    '     .  588 

123.  Extreme  Anteflexion  of  Uterus,         ........  590 

124.  Anteflexion  of  Uterus, 591 

125.  Diagnosis  of  Anteflexion  of  Uterus,  ........  592 

126.  Mode  of  applying  Hodge  or  Lever  Pessary  for  Eetroflexion,     .         .         .  598 

127.  Second  Stage  in  Application  of  the  Hodge, 599 

128.  Third  and  Final  Stage, 600 

129.  Extreme  Eetroflexion  of  Uterus,        ........  603 

130.  Diagnosis  of  Eetroflexion  by  Vaginal  Touch,    ......  607 

131.  Diagnosis  and  Eeposition  of  Eetroflected  Uterus  by  the  Sound,        .         .  609 

132.  Occasional  Vicious  Action  of  the  Hodge  in   Extreme  Eetroflexion  of 

Uterus,     . 613 

133.  Combination  of  Intra-Uterine  Pessary  and  the  Hodge,     ....  614 

134.  Illustrating  Three  Degrees  of  Inversion  of  Uterus  (Crosse),     .         .         .  616 

135.  Extreme  Inversion  in  Section  (Crosse),     .......  617 

136.  Specimen  of  Inverted  Uterus  (Crosse), 617 


XVI 


LIST    OF    WOOD    ENGRAVINGS. 


B'lG-  PAGE 

137.  Barnes's  Operation  for  Inversion  of  Uterus,      ......  636 

138.  Barnes's  Elastic  Pessary  for  Eeduction  of  Chronic  Inversion  of  Uterus,  638 

139.  Structure  of  Fibroid  of  Uterus  (Arnott), 642 

140.  Conglomerate  of  Fibroid  Tumors  of  Uterus  (St.  Thomas's),     .         .         .  644 

141.  Subperitoneal  Fibroid  Tumor  of  Uterus  (London  Hospital),    .         .         .  645 

142.  Fibroid  Tumor  of  Uterus  (St.  Thomas's), 646 

143.  Uterus  with  two  large  Fibroid  Tumors  (St.  George's),     ....  647 

144.  Fibrous  Tumors  of  Uterus  (St.  George's), 649 

14-5.  Fibroid  or  Muscular  Tumor  of  Uterus  (St.  Thomas's),     ....  650 

146.  Erectile  Tumor  of  Uterus  (Carswell), 6-52 

147.  Ossified  Fibroid  Tumor  of  Uterus  (St.  Thomas's), 655 

148.  Fibroid  Polypus  filling  Cavity  of  Uterus  (College  of  Surgeons),       .         .  678 

149.  Fibroid  Polypus  extruded  from  Cavity  of  Uterus  (College  of  Surgeons),  678 

150.  Fibroid  Polypus  moulded  to  shape  of  Uterine  Cavity  (College  of  Sur- 

geons),        679 

151.  Mucous  or  Glandular  Cervical  Polypus,     .......  683 

1-52.  Section  of  "  Channelled  "  Glandular  Polypus  (Arnott),     ....  684 

153.  Uterus  with  Fibrous  Polypus  attached  to  Upper  "Wall  and  ligatured 

(Bartholomew's), 691 

154.  Aveling's  Polyptrite, 692 

155.  Operation  for  removing  Polypus  by  Wire  Ecraseur,          ....  693 

156.  Tubercular  Disease  of  Uterus  (Guy's),       .' 698 

157.  Phthisis  Uteri  (Carswell), 699 

158.  Cancer  of  Uterus  (Bartholomew's),  ........  707 

159.  Uterus  enlarged  from  Infiltration  with  Encephaloid  Matter  (St.  Thomas's),  708 

160.  Uterus  lower  two-thirds  Destroyed  by  Ulceration  (Bartholomew's),         .  709 

161.  Cancer  eating  away  lower  half  of  Uterus  (St.  Thomas's),          .         .         .  709 

162.  Pavement  Epithelioma  of  Uterus  (Lancereaux), 711 

163.  Malignant  Disease  of  Uterus  (St.  George's),      ......  712 

164.  Cauliflower  Growth  of  Cervix  Uteri  (Arnott), 713 

165.  Spindle-cell  Sarcoma  (Arnott), 714 

166.  Intra-Uterine  Speculum,    ..........  737 

167.  Cicatricial  Band  Binding  Os  Uteri  to  Koof  of  Vagina,     ....  746 

168.  Syphilitic  Hypertrophy  of  Nympha, 763 

169.  Hypertrophic  Lupus  of  Vulva, 764 


TEEATISE 


DISEASES    OF    WOMEN. 


INTRODUCTORY. 

It  may  seem  superfluous  to  state  that  a  clear  knowledge  of  anatomy 
is  the  antecedent  condition  of  a  correct  understanding  of  disease,  diag- 
nosis, and  treatment.  All  sound  medicine  is  based  upon  this  proposi- 
tion. But  it  is  more  strictly  true  of  the  diseases  of  women  than  it  is  of 
disease  in  general.  For  example,  it  is  quite  possible  to  imagine  a  satis- 
factory diagnosis  to  be  made  of  a  fever  and  to  treat  it  successfully, 
without  any  precise  knowledge  of  anatomy  ;  but  in  the  diagnosis  and 
treatment  of  morbid  conditions  of  the  female  pelvic  organs  it  is  hardly 
possible  to  move  a  step  without  precise  knowledge  of  their  anatomy 
and  physiology  ;  that  is,  without  imminent  risk  of  falling  into  error  in 
practice. 

It  therefore  becomes  especially  desirable  to  introduce  the  study  of 
the  medical  and  surgical  diseases  of  women  by  an  adequate  description 
of  the  organs  specially  concerned.  It  might  be  thought  to  be  suffi- 
cient to  refer  the  reader  for  this  to  any  one  of  the  many  admirable  works 
on  anatomy  which  Ave  now  possess  ;  but  this,  it  would  quickly  be  found 
would  very  imperfectly  answer  the  purpose.  Anatomical  text-books 
teach  j)iure  anatomy  only,  certainly  as  far  as  the  diseases  of  women  are 
concerned.  What  we  want  is  the  applied  anatomy  of  the  sexual 
system. 

Almost  every  physiological  or  pathological  condition  of  the  pelvic 
organs  is  attended  by  variations  more  or  less  marked  either  in  their 
tissues,  in  their  shape,  size,  or  in  their  relative  positions,  and  often  in 
all.  Hence  the  necessity  of  keeping  constantly  before  us  the  normal 
standard  by  which  we  may  estimate  the  abnormal  deviations  and  un- 
derstand how  these  are  to  be  corrected. 

The  principal  organs  we  are  concerned  with  are  all  contained  loithin 
the  true  pelvis.  They  are  further  inclosed  or  packed  between  the  peri- 
toneum above  and  the  perineum  below. 

2 


18  IISTTEODUCTOR  Y. 

These  organs  are,  the  uterus,  the  Fallopiau  tubes,  the  ovaries,  the 
vagina,  and  vulva.  The  rectum  and  bladder,  also  contained  within 
the  same  region,  are  indirectly  important,  in  consequence  of  their  phys- 
iological and  pathological  relations  to  the  genital  organs. 

The  pelvic  organs  are  all  related  to  each  other  by  position  or  by  con- 
necting tissues. 

The  connective  tissue  being  distributed  everywhere  at  the  points  of 
union  of  the  organs,  carries  the  bloodvessels,  nerves,  and  lymphatics 
to  the  organs. 

In  certain  parts  this  connective  tissue  is  limited  by  fasciae. 

In  addition  to  these  organs,  we  have  to  remember  that  the  pelvis  is 
traversed  by  bloodvessels  and  nerves,  which  are  not  strictly  related 
to  the  genital  organs,  but  which  are  liable  to  be  implicated  in  various 
ways,  as  by  pressure,  during  gestation  and  labor,  by  tumors,  or  dis- 
placement of  the  ovaries  or  uterus.  These  vessels  and  nerves  lie  in 
close  contact  with  the  walls  of  the  pelvis,  and  have  their  exit  at  the 
sacro-sciatic  notches,  at  the  brim  under  Poupart's  ligament,  and  the 
obturator  foramina. 

Then  there  are  muscles,  all  cushioned  by  fat  and  cellular  tissue. 


CHAPTEK  I. 

THE   GENITAL   ORGANS. 
OVARIES  —  CORPUS    LUTEUM. 

The  genital  organs  consist  of,  1st,  two  glands,  the  ovaries,  in  which 
the  ova  are  formed ;  2d,  the  tderine  tubes,  called  Fallopian,  which  are 
true  excretory  ducts  to  the  ovaries ;  3d,  the  uterus,  a  muscular  organ 
in  which  the  fecundated  ovum  is  received  and  is  developed,  and  which 
is  the  principal  agent  in  the  expulsioij  of  the  foetus ;  4th,  the  vagina,  a 
canal  which  connects  the  uterine  cavity  with  the  exterior,  and  serves  in 
copulation ;  5th,  the  vulva,  an  assemblage  of  organs  placed  around  the 
entrance  of  the  genital  organs.  Associated  with  the  genital  organs  are 
the  breasts,  whose  function  it  is  to  secrete  the  milk,  the  first  nourish- 
ment of  the  infant. 


Transverse  section  just  above  pelvic  rim,  showing  the  relative  position  of  the  organs  as  seen  from 

above — (after  Savage), 
m,  pubes ;  a,  a,  (in  front)  remains  of  hypogastric  arteries;  a,  a,  (behind)  spermatic  vessels  and 
nerves ;  b,  bladder ;  l,  l,  round  ligaments  ;  u,  uterus  seen  by  its  fundus  ;  t,  i,  Fallopian  tubes ;  o,  o, 
ovaries  ;  r,  rectum  ;  g,  right  ureter  resting  on  the  psoas  muscle  ;  c,  utero-sacral  ligaments  forming  the 
lateral  borders  of  Douglas's  pouch  ;  v,  last  lumbar  vertebra. 

1.  The  ovaries  are  so  called  from  their  containing  small  vesicles  or  ova. 
They  are  two ;  they  are  placed  in  front  of  the  rectum,  from  which  they 


20  ANATOMY. 

are  often  separated  by  convolutions  of  the  small  intestine,  on  either  side 
of  the  uterus,  behind  the  Fallopian  tubes,  and  in  that  portion  of  the 
broad  ligaments  Avhich  is  called  the  posterior  wing  or  fold.  They  are 
maintained  in  position  by  the  broad  ligaments,  which  make  for  them  a 
kind  of  mesentery,  and  by  a  special  ligament,  the  ligament  of  the  ovary. 
The  situation,  however,  varies  according  to  the  age  and  the  condition  of 
the  uterus.  In  the  fcetus,  they  are  placed  in  the  lumbar  region,  like 
the  fundus  of  the  uterus.  During  pregnancy  they  rise  in  the  abdomen 
with  the  body  of  the  uterus,  to  the  sides  of  which  they  are  applied. 
Immediately  after  delivery,  they  occupy  the  internal  iliac  foss£e,  where 
they  sometimes  remain  throughout  life,  fixed  by  accidental  adhesions. 
Frequently  they  are  found  turned  backwards  and  adhering  to  the  pos- 
terior surface  of  the  uterus.  Sometimes  an  ovary  is  found  in  the  sac 
of  an  inguinal,  a  femoral,  or  even  of  an  umbilical  hernia. 

Cases  have  been  met  with  in  which  no  ovaries  were  found.  It  must 
be  very  rare  that  organs  so  essential  are  absolutely  wanting  ah  initio. 
There  is  a  preparation  in  University  College  Museum  from  a  girl,  aged 
20,  who  had  never  menstruated.  The  uterus  presents  the  features 
characteristic  of  early  childhood,  and  no  ovaries  are  manifest.  "When 
not  discovered,  the  ovaries  may  have  disappeared  by  atrophy,  the  result 
of  some  morbid  process. 

The  size  of  the  ovary  varies  according  to  age,  the  condition  of  the 
uterus,  and  health  or  disease.  In  the  adult  it  measures  an  inch  to  two 
inches  in  length,  an  inch  in  breadth,  and  half  an  inch  in  thickness. 
The  average  weight  is  87  grains.  It  is  proportionally  larger  in  the 
foetus;  it  diminishes  after  birth,  it  enlarges  considerably,  becoming 
softer  and  more  vascular  at  the  epoch  of  puberty,  and  becomes  atro- 
phied and  hard  in  old  age.  Towards  the  end  of  pregnancy  it  acquires 
double  or  treble  the  size  of  the  ordinary  state. 

The  shape  is  that  of  an  ovoid  a  little  flattened  from  before  backwards ; 
the  outer  extremity,  that  looking  towards  the  fimbriated  end  of  the 
Fallopian  tube,  is  rounder  and  thicker  than  the  inner  extremity,  which 
looks  towards  the  uterus.  The  anterior  surface,  like  that  of  the  uterus, 
is  flatter  than  the  posterior,  which  is  gibbous.  The  upper  border  is 
convex ;  the  lower  one  is  straight  or  concave.  The  color  is  whitish. 
The  surface  is  smooth  during  childhood  (as  seen  in  Fig.  2) ;  after  pu- 
berty it  becomes  rough,  scarred  by  repair  of  the  rents  made  in  the  tissues 
to  afibrd  escape  to  the  ova  at  the  menstrual  periods  (as  seen  in  Fig.  3). 
The  ovary  is  free  in  front,  above,  and  behind ;  it  floats  in  the  pelvic 
cavity,  fastened,  1st,  by  its  lower  border  to  the  broad  ligament  wliich 
is  furnished  with  a  peritoneal  investment,  and  represents  the  hilum  of 
the  gland.  Along  this  border  bloodvessels  penetrate  and  emerge ;  2d, 
it  is  fastened  by  its  outer  extremity  to  the  pavilion  of  the  Fallopian 
tube  (see  Fig.  3);  and  3d,  by  its  inner  extremity  to  the  corresjionding 
side  of  the  uterus,  a  little  below  the  superior  angle  of  this  organ,  by  a 
cord  named  the  ligament  of  the  ovary  (see  h,  Fig.  3).  This  cord  is 
fibrous  and  muscular,  and  is  simply  a  prolongation  of  the  proper  tissue 
of  the  uterus. 

The  structure  of  the  ovary  is  composed  of  an  investment  and  paren- 
chyma.    The  investing  structure  consists  of  the  peritoneal  or  serous  coat, 


THE    OVARIES. 


21 


and  of  an  inner  fibrous  coat,  called  also  the  tunica  albuginea  ;  but  the 
two  are  so  intimately  blended  that  it  is  impossible  to  separate  them ; 
nor  is  it  easier  to  separate  the  fibrous  coat  from  the  parenchyma.     The 


Fifi.  2. 


^E 


Adult  parovarium,  ovary,  and  Fallopian  tube — (after  Kobelt). 
a,  a,  tubules  of  the  original  Wolffian  body  or  parovarium  ;  6,  remains  of  the  upper  set  which  occa- 
sionally become  distended  by  collections  of  fluid,  and  constitute  one  form  of  dropsy  of  the  broad  liga- 
ment ;  c,  middle  set  of  tubules  ;  d,  lower  set  atrophied ;  e,  atrophied  remains  of  the  excretory  duct  of 
the  WoMan  body  ;  /,  terminal  bulb  of  the  same,  converted  here  into  the  hydatid  often  seen  attached 
to  the  broad  ligament ;  h,  the  former  duct  of  Miller,  now  the  Fallopian  tube,  with  its  infundibulum, 
from  which  hangs  i,  the  terminal  bulb,  now  converted  into  a  pedunculated  hydatid  ;  I,  generative 
gland,  now  the  ovary. 

bundles  of  connective  tissue  composing  this  coat  are  arranged  in  seve- 
ral layers,  circular  or  longitudinal.  Within  this  is  a  layer  of  connec- 
tive tissue,  the  bundles  of  which  are  crossed  in  every  direction :  this 


Eight  Fallopian  tube  laid  open.    Prom  an  adult  who  had  not  borne  children — (after  Eichard). 
a,  funnel-shaped  canal,  leading  from  the  uterus  to  6,  uterine  portion  of  the  tube  ;  c,  point  at  which 
the  large  plicte  commence  ;  d,  infundibulum  covered  by  plicce,  continuous  with  those  lining  the  canal ; 
e,  tubo-ovarian  ligament  and  fringes  ;  /,  ovary  ;  g,  round  ligament ;  h,  ligament  of  the  ovary. 

belongs  to  the  parenchyma,  although  the  naked  eye  fails  to  distin- 
guish the  boundary  that  divides  it  from  the  fibrous  coat.  On  making 
an  antero-posterior  section  of  the  ovary,  the  parenchyma  is  seen  to  be 


22  A  N  A  T  O  M  Y. 

formed  of  two  distinct  parts :  the  one  central  or  medullary,  the  other 
peripheral  or  cortical.  The  medullary  substance  looks  spongy  and  red, 
owing  to  the  vessels  of  the  hilum  which  ramify  in  its  interior.  The 
color  gradually  fades  into  a  grayish- white,  and  as  the  cortical  substance 
is  approached,  it  becomes  quite  white.  The  medullary  substance  is 
formed  of  connective  tissue ;  the  large  bundles  of  the  connective  fibres 
are  arranged  in  a  parallel  direction  to  the  vessels,  and  from  these  bun- 
dles spring  nets  of  more  delicate  fibres  which  fill  up  the  interspaces. 
Around  the  first  are  often  twined  nets  of  very  fine  elastic  fibres ;  and 
in  the  neighborhood  of  the  larger  arteries  these  elastic  fibres  are  often 
mixed  with  parallel  bundles  of  smooth  muscular  fibres  prolonged  from 
those  which  compose  the  ligament  of  the  ovary.  M.  Rouget'  says 
these  muscular  fibres  constitute,  the  vessels  excepted,  the  principal  mass 
of  the  medullary  substance ;  that  the  greater  number  proceed  from  the 
posterior  surface  of  the  uterus,  and  that  they  reach  the  ovary  either  by 
the  round  ligament  or  by  the  broad  ligament,  whilst  others  spring  from 
the  fascia  propria  of  the  lumbar  region,  accompanying  the  spermatic 
vessels  which  they  surround. 

M.  His^  is  even  of  opinion  that  the  entire  interstitial  tissue  of  the 
ovaries  is  nothing  but  a  peculiarly  modified  and  confused  mass  of  mus- 
cular tissue,  and  he  proposes  for  it  the  name  "  fusiform  mass."  Rouget 
regards  the  arrangement  by  which  these  muscular  fasciculi  accompany 
the  vessels  in  the  form  of  sheaths,  as  analogous  to  that  which  obtains 
in  erectile  tissues.  Waldeyer,  however,  says^  that  at  present  we  cannot 
be  said  to  possess  any  direct  observations  on  the  erection  of  the  ovaries. 

The  peripheral  or  cortical  portion  constitutes  the  essential  part  of  the 
ovary,  that  in  which  the  ovule  is  formed.  In  it  are  distinguished  :  1. 
The  ovisacs  or  Gh^aafian  vesicles,  destined  to  secrete  and  expel  the  ovum ; 
2.  An  intermediate  structure  in  which  vesicles  are  scattered.  This  is 
called  the  stroma. 

Immediately  beneath  the  tunica  albuginea  the  stroma  is  composed  of 
bundles  of  connective  tissue  variously  crossed ;  near  the  medullary 
substance  it  presents  the  irradiations  of  the  connective  fibres  of  this 
part.  What  distinguishes  the  connective  tissue  is  the  enormous  quantity 
of  interstitial  nuclei  revealed  by  acetic  acid.  Between  these  two  layers 
of  connective  tissue  is  a  layer,  the  variable  thickness  of  which  mainly 
determines  the  differences  in  size  which  the  ovary  presents.  It  consists 
essentially  of  fusiform  nucleated  cells,  strongly  compressed  against  each 
other,  and  sometimes  furnished  with  filiform  prolongations,  very  short 
and  penetrating  into  the  interstices  of  the  adjoining  cells.  The  Graafian 
vesicles  or  follicles  are  scattered  in  the  stroma  of  the  cortical  substance, 
chiefly  in  the  most  superficial  layer.  The  limitation  of  the  ovules  to 
the  peripheral  portion  is  most  marked  in  infancy.  After  puberty  they 
are  apt  to  invade  the  medullary  portion.  Towards  puberty  the  folli- 
cles are  found  close  together.  Their  number  is  very  great.  To  give 
an  approximate  idea,  Henle  makes  the  following  calculation :  In  the 

'  "Journal  de  la  Physiologie,"  i,  p.  737. 

2  "  Beobachtungen  iiber  den  Bau  des  Saiigethiereierstocks."  Max  Schultze's 
Archiv  f.  mikrosp.  Anat.,  1865. 

3  Strieker's  "  Manual  of  Histology,"  N.  Sydenham  Soc.,1872.  ' 


THE    OVARIES. 


23 


ovary  of  a  person  eighteen  years  old  an  antero-posterior  section,  form- 
ing about  a  sixth  of  the  periphery  of  the  organ,  showed  20  follicles ; 
in  the  entire  section  there  would  be  120  follicles;  and  as  it  would  be 
possible  to  divide  the  ovary  into  300  sections,  it  follows  that  each  ovary 
contained  300  times  120,  or  36,000  follicles,  or  72,000  for  each  woman. 

The  follicles,  at  first  microscopic,  rapidly  grow  after  puberty  when 
they  are  destined  to  mature.  They  invade  the  medullaiy  substance, 
and  form  a  hemispherical  bulging  on  the  surface  of  the  ovary.  This 
ripening  appears  to  take  place  rapidly,  since  only  a  small  number  of 
follicles  is  usually  made  out  by  the  naked  eye ;  that  is,  in  process  of 
development ;  yet  it  is  certain  that  every  month  one  follicle,  at  least, 
arrives  at  complete  maturation. 

When  ripe,  the  follicle  consists  of  an  investing  membrane  and  contents. 
1.  The  investing  membrane  presents  an  outer  or  fibrous  tunic,  a  middle 
or  proper  tunic,  and  an  inner  or  epithelial  or  granular  layer.  The  first 
is  thick,  very  vascular,  and  very  retractile ;  it  is  united  to  the  stroma 
by  a  loose  cellular  tissue :  hence  it  is  easily  isolated.  It  is  formed  of 
compact  bundles  of  connective  tissue  arranged  in  concentric  layers. 
The  tunica  propria  is  also  composed  of  connective  tissue ;  but  this  is 
in  a  more  embryonic  state,  and  contains  a  multitude  of  nuclei  and 
fusiform  cells.  This  tunic  is  also  much  less  retractile  than  the  fibrous 
tunic.  The  epithelium  which  lines  the  membrane  of  the  follicle  inside 
is  composed  of  one  or  more  layers  of  polygonal  cells,  inclosing  a  large 
nucleus  and  some  fatty  granules.  The  epithelium  is  much  thicker  at 
the  part  which  surrounds  the  ovum.     At  the  level  of  this  part  the  ac- 


— A 


A,  A,  ovary  enlarged  under  menstrual  nisus ;  b,  ripe  follicle  projecting  on  surface;  a,  a,  a,  traces  of 
previously  burst  follicles — (after  Raciborski). 


cumulated  cells  form  a  warty  swelling,  which  bulges  into  the  cavity  of 
the  follicle.  This  swelling  is  the  cumulus  or  discus  proligerus.  The 
ovum  is  situated  in  the  middle  of  the  cells  of  the  proligerous  disk,  part 
of  which  it  carries  along  with  it,  when,  after  the  dehiscence  of  the  fol- 
licle, it  leaves  the  ovary  to  enter  the  oviduct.    The  ovum  is  a  spherical 


24  ANATOMY. 

vesicle  ;  it  may  be  represented  as  a  simple  cell.  The  membrane  of  the 
cell  is  called  the  vitelline  membrane  ;  it  is  very  thick,  perfectly  hyaline 
and  transparent,  resisting  and  very  elastic.  The  contained  matter  is 
called  the  vitellus;  this  is  a  viscous  liquid,  of  yellowish  color,  in  which 
are  seen  a  multitude  of  granulations.  A  large  vesicular  nucleus,  called 
the  germinal  vesicles,  is  situated  excentrically  in  the  vitellus,  and  itself 
contains  a  small  nucleolus,  the  germinal  spot.  It  is  rare  to  find  two  ova 
in  the  same  follicle. 

The  follicle  contains  a  transparent,  yellowish  fluid,  resembling  serum ; 
at  first  this  is  very  small  in  quantity,  but  increases  gradually  as  the 
follicle  approaches  maturation,  until  the  tunics,  swollen  and  thinned  by 
this  accumulation  of  liquid,  burst  at  the  culminating  point,  and  dis- 
charge their  contents. 

Corpoixi  lutea. — When  the  follicles  have  burst,  and  the  ovum  has 
escaped,  a  process  takes  place  which  results  in  the  formation  of  the  so- 
called  yellow  bodies.  On  the  bursting  of  the  follicle,  its  membranes 
collapse.  The  retraction  is  due  entirely  to  the  fibrous  membrane ;  the 
internal  membrane  and  the  granular  layer  having  no  elasticity  simply 
follow  the  movements  of  the  fibrous  tunic,  and  form  folds,  just  as  the 
mucous  membrane  of  the  stomach  does  under  the  influence  of  the  con- 
traction of  the  muscular  coat.  The  cavity  of  the  follicle  is  thus  greatly 
contracted ;  a  small  quantity  of  blood,  escaped  from  some  ruptured 
vessel,  is  retained,  but  only  as  an  exception,  according  to  Coste,  in  the 
cavity,  which  is  early  invaded  by  a  plastic  and  gelatinous  secretion 
furnished  by  the  inflamed  part.     Soon  the  cellular  and  granular  layer, 

Fig.  5. 


Showing  menstrual  corp.  lut.  and  ovary — (after  Eaciborski). 
B,  cavity  of  Graafian  sac  from  which  ovum  has  escaped ;  6,  clot  of  blood  in  sac. 

a  part  of  which  has  been  expelled  with  the  ovum,  undergoes  a  kind  of 
hypertrophy,  which  gives  it  an  enormous  size.  Every  cell  becomes 
about  six  times  as  large  as  before ;  this  growth  is  especially  due  to  the 
accumulation,  in  the  inside  of  the  cells,  of  a  multitude  of  yellow 
granules  of  albuminous  nature,  giving  to  the  whole  follicle  the  color 


THE    OVARIES.  25 

which  suggested  the  name  of  yellow  body.  Owing  to  this  hypertrophy 
and  to  the  folding  of  the  inner  membrane,  the  cavity  of  the  follicle  is 
at  last  completely  closed.  The  circumvolutions  of  the  inner  membrane 
coming  into  contact  grow  together ;  and  even  after  having  obliterated 
the  cavity  they  continue  to  grow,  and  thus,  not  finding  room  in  the 
retracted  external  tunic,  they  often  project  as  a  hernia  through  the  rent 
of  the  follicle,  and  are  seen  outside  resembling  luxuriant  fleshy  granu- 
lations. At  this  stage  the  burst  follicle  is  a  rounded  tumor,  bulging  on 
the  surface  of  the  ovary,  in  size  sometimes  equal  to  or  exceeding  that 
of  the  rest  of  the  organ.  The  process  which  gives  rise  to  the  corpus 
luteum  begins  soon  after  the  escape  of  the  ovule,  and  increases  in  activity 
up  to  the  thirtieth  or  fortieth  day  of  pregnancy.  The  yellow  bodies 
then  remain  stationary  until  near  the  end  of  the  third  month,  and  from 
that  date  they  begin  to  decline ;  the  convolutions,  united  together  by 
adhesions  more  or  less  intimate,  atrophy  and  leave  true  fibrous  bands ; 
at  the  same  time  the  yellow  granulations  are  absorbed,  the  cells  disap- 
pear, whilst  the  vessels  retract  and  are  atrophied.  At  the  moment  of 
labor  the  corpora  lutea  are  still  large,  but  the  process  of  absorption 
goes  on  after  delivery,  and  ends  by  bringing  about  their  complete  dis- 
appearance. Then  there  remains  on  the  surface  of  the  ovary  nothing 
but  an  irregular  scar  to  mark  the  place  of  the  rupture. 

There  are  considerable  differences  in  the  evolution  of  the  corpora 
lutea.  The  most  remarkable  is  that  which  depends  upon  whether  the 
discharge  of  the  ovum  has  been  followed  by  pregnancy  or  not.  In  the 
latter  case  the  yellow  bodies  run  through  all  their  stages  rapidly,  and 
never  reach  a  great  development ;  these  have  been  called  false  cotyora 
lutea.  They  wither  early ;  and,  at  the  end  of  one  or  two  months,  only 
traces  of  them  are  found  on  the  surface  of  the  ovary. 

The  Vessels  of  the  Ovary. — The  ovary  is  extremely  vascular;  its 
arteries  spring  from  a  trunk  common  to  the  ovary  and  the  uterus — the 
utero-ovarian  artery.  Having  reached  the  inferior  border  of  the  ovary, 
this  artery,  which  springs  from  the  aorta  on  the  level  of  the  renal  artery, 
and  which  is  remarkable  for  its  flexuous  course,  suddenly  gives  off  ten 
or  twelve  branches.  These  ascend  in  a  parallel  direction,  describing 
numerous  flexuosities,  divide,  intertwine,  and  penetrate  the  ovary  at 
its  lower  margin  or  hilum.  In  the  thickness  of  the  medullary  sub- 
stance the  arterial  ramifications  subdivide  and  anastomose,  always  pre- 
serving their  spiral  disposition.  From  the  medullary  substance  the 
arteries  spread  into  the  stroma  of  the  cortical  substance,  and  on  the 
walls  of  the  Graafian  follicles. 

The  veins  of  the  ovary,  voluminous  and  plexiform,  arise  from  the 
capillary  networks  which  surround  the  Graafian  follicles.  Their  radi- 
cles unite  into  small  trunks  twisted  spirally,  and  run  to  the  hilum 
coursing  between  the  arteries,  where  they  form  a  kind  of  vascular  bulb, 
the  ovarian  bulb  of  Rouget.  Directly  below  the  ovary  these  veins 
form  a  rete  mirabile,  the  vessels  of  which  are  distant  0.04  inch  to  0.12 
inch  from  each  other,  a  true  corpus  spongiosum  described  by  M.  Jarja- 
vay  in  1852.^ 

^  "Anatomie  Chirurgicale,"  vol.  i,  p.  288. 


26 


ANATOMY. 


According  to  M.  Rouget^  this  is  traversed  in  all  directions  by  mus- 
cular fibres,  constituting  an  erectile  organ  comparable  to  the  bulb  of 
the  vestibule.  From  the  outer  part  of  this  bulb  proceed  two  veins, 
which  run  to  empty  themselves  directly  into  the  vena  cava  on  the  right 
side,  and  into  the  renal  vein  on  the  left.  The  ovarian  veins  receive 
almost  immediately  after  leaving  the  ovary,  the  veins  issuing  from  the 
body  of  the  uterus,  and  now  earn  the  name  of  utero-ovarian  veins. 
They,  like  the  arteries,  are  of  enormous  size  at  the  end  of  gestation,  and 
immediately  after  delivery. 

Fig.  6. 


Bulb  of  ovary — (after  Savage;. 
The  venous  erectile  system  of  the  ovary,  the  anterior  layer  of  the  tubo-ovarian  mesentery  dissected 
off.    u,  uterus  ;  o,  ovary  and  utero-ovarian  ligament ;  t,  Fallopian  tube.    1.  Utero-ovarian  vein ;  2. 
Pampiniform  venous  plexus  ;  3.  Commencement  of  spermatic  vein. 

The  lymphatiG  vessels  follow  the  course  of  the  ovarian  arteries  and 
veins.  Their  radicles,  still  little  known,  unite  into  small  trunks,  which 
issue  from  the  ovary  at  the  hilum,  and  run  to  the  lumbar  ganglions. 
According  to  His,  lymphatics  are  found  in  the  hilum;  moreover,  he 
says,  wide  sac-like  lymphatics  are  here  found,  which  invest  the  follicle 
and  yellow  body  like  a  shell,  and  are  the  cause  of  the  easy  isolability 
of  these  structures.  They  are  often  found  filled  with  pus,  the  conse- 
quence of  puerperal  peritonitis,  which  is  often  complicated  with  ovaritis 
and  inflammation  of  the  lymphatic  vessels. 

The  nerves  of  the  ovary  proceed  from  the  ovarian  plexus,  which 
comes  from  the  renal  plexus. 

Development. — The  ovaries,  like  the  testicles,  are  developed  at  the 
expense  of  a  secondary  blastema,  which  forms  upon  the  inner  edge  of 
the  Wolffian  body.  They  are  relatively  larger  in  the  foetus  than  in 
the  adult.  This  great  proportional  development  is  especially  observed 
in  the  length ;  for,  instead  of  being  ovoid,  they  are  thin  and  flattened. 
The  surface  is  perfectly  smooth  and  polished.  Placed  outside  the 
cavity  of  the  pelvis,  in  the  lumbar  region,  it  seems  analogous  in  this 
respect  to  the  testicle.  But  this  appears  to  be  due  simply  to  the  want 
of  development  of  the  pelvis,  the  bladder  and  uterus  being  also  as  yet 
seated  in  the  abdomen.  At  this  period  the  ligament  of  the  ovary  is  so 
little  developed  that  the  inner  extremity  of  the  ovary  touches  the  cor- 
responding border  of  the  uterus.     The  ovarian  follicles  exist  already 


•  Anatomie  Pathologique,"  17*  livraison. 


THE    OVARIES.  27 

in  the  foetus ;  and,  at  the  moment  of  birth,  they  are  seen  in  very  com- 
pressed layers  throughout  the  whole  cortical  substance  of  the  ovary. 
They  are  composed  of  a  small  rounded  mass  of  granular  substance,  sur- 
rounded by  a  simple  layer  of  cells.  The  stroma  divides  them  into 
groups,  separated  from  each  other  by  bundles  of  connective  tissue, 
which  send  finer  prolongations  betsveen  the  follicles  of  each  group. 
An  extremely  fine  membrane  bounds  the  follicles  externally.  On  the 
inner  surface  is  a  layer  of  epithelial  cells,  each  of  which  contains  an 
elongated  nucleus.  The  contents  of  the  follicles  consist  of  a  finely 
granular  substance,  in  which  is  distinguished  a  spherical  transparent 
vesicle.  The  ovaries  are  extremely  small  after  birth,  and  undergo  no 
change  until  the  epoch  of  puberty.  This  epoch  is  more  precocious  for 
the  ovaries  than  for  the  other  genital  organs.  In  girls  of  thirteen  and 
fourteen  years  old,  whose  internal  genital  organs,  and  the  uterus  itself, 
still  showed  all  the  characters  of  the  foetal  state,  the  ovaries  had  already 
acquired  their  full  development :  they  were  ovoid,  soft,  spongy,  and 
full  of  blood. 

At  the  epoch  of  puberty  very  important  changes  take  place  in  the 
ovary,  the  merit  of  pointing  out  which  is  due  to  Negrier,'  Gendrin,^ 
Gird  wood,  Pouchet,  Letheby,^  Bischoff,*  and  Raciboi'ski.  From  the 
facts  brought  to  light  by  these  observers  it  results :  1st.  That  every 
menstrual  period  is  accompanied  in  the  ovary  by  a  particular  process, 
which  appears  to  be  limited  to  one  Graafian  follicle,  which  increases 
remarkably  in  size,  raises  and  thins  the  fibrous  investment  of  the  ovary, 
and  finally  ruptures  it.  2d.  That  this  rupture  of  the  Graafian  follicle 
has  for  its  object  to  permit  the  passage  of  the  ovule  of  Baer  into  the 
Fallopian  tube.  3d.  That  hence  there  takes  place  in  woman,  at  every 
menstrual  period,  independently  of  any  special  cause,  something  analo- 
gous to  the  spontaneous  oviposition  of  the  Ovipara.  4th.  That  the 
same  phenomenon  is  effected  in  the  females  of  the  Mammalia  at  the 
time  of  heat.  5th.  That  the  follicle  of  Graaf,  immediately  after  its 
bursting,  becomes  the  seat  of  a  special  pi:ocess,  which  gives  rise  to  the 
corpus  luteum.  6th.  That  in  consequence  of  the  work  of  resorption  in 
the  corpus  luteum,  the  follicle  will  be  replaced  by  a  slate-colored  cica- 
trix, which  penetrates  more  or  less  deeply  into  the  substance  of  the 
ovary.  7th.  Lastly,  that  the  cicatrices  or  scars  on  the  surface  of  the 
ovaries  and  the  corpora  lutea,  are  not  the  result  of  follicles  torn  by  the 
act  of  fecundation  or  of  any  erotic  excitation,  as  Haller  believed. 

The  ovaries  maintain,  throughout  the » period  of  menstrual  life,  the 
development  acquired  at  the  epoch  of  puberty.  Throughout  this  period, 
also,  we  meet  with  Graafian  follicles  in  progress  to  maturation,  so  that 
the  question  arises :  Do  the  vesicles,  formed  in  such  multitude  in  the 
foetus,  continue  without  change  until  the  time  when  they  are  roused  to 
complete  development,  that  is,  from  the  age  of  fifteen  to  fifty  ?  or  are 
these  first  vesicles  destroyed  at  the  end  of  a  certain  time,  to  be  replaced 

1  "  Recherches  anatomiques  et  physiologiques  sur  les  ovaires  de  I'espece  humaine," 
&c.     Paris,  1840. 

-  "  Traite  philosophiques  de  Medecine  pratique."     Paris,  1839. 

3  Philosophical  Transactions,  1852. 

*  "  Zeitschrift  fiir  rationelle  Medicin,"  1853. 


28  ANATOMY. 

by  others  of  more  recent  formation  ?  Another  question,  not  less  inter- 
esting, is  whether  a  single  vesicle  arrives  at  maturity  at  each  menstrual 
period,  or  whether  several  accomplish  their  full  development  at  the 
same  time  ? 

These  questions  are  not  yet  clearly  solved.  Sometimes  several  corpora 
lutea  are  found  in  the  same  ovary.  If  only  a  single  vesicle  were  spent 
at  each  menstruation,  it  would  take  about  300  vesicles  for  the  same 
number  of  menstruations,  which,  excluding  the  suspensions  during 
pregnancy  and  suckling,  take  place  during  the  reproductive  period  of 
life.  Setting  aside,  therefore,  the  possibility  of  the  new  formation  of 
vesicles,  there  exist  in  the  ovary  of  the  fcetus  infinitely  more  vesicles 
than  are  wanted  for  all  the  purposes  of  reproduction.  After  the  critical 
epoch  the  ovary  is  deprived  of  follicles.  It  shrinks,  shrivels,  and  in 
old  age  loses  its  ovoid  form,  becomes  flattened,  atroj)hied,  rough,  knot- 
ted, and  seems  reduced  to  its  shell. 

Fig.  7. 


Showing  ovary  in  old  age — (ad  nat.). 

Bischoff  says  that  in  every  instance  the  full  consequences  of  menstru- 
ation are  not  necessarily  carried  out,  but  that  a  follicle  may  swell  and 
the  ovum  ripen  without  the  bursting  of  the  follicle  or  the  escape  of  the 
ovum.  Such  a  condition  will  cause  sterility  notwithstanding  menstru- 
ation. 

The  ovaries,  then,  are  the  essential  organs  of  generation.  The  de- 
struction of  one  ovary  by  disease,  or  its  loss  by  extirpation,  does  not 
entail  sterility  ;  but  the  destruction  or  loss  of  both  condemns  the  woman 
to  absolute  sterility. 

In  connection  wdth  the  history  of  the  ovary,  it  is  convenient  to  de- 
scribe an  organ  immediately  contiguous — the  organ  or  body  of  Rosen- 
rniUler.  This  body  is  placed  in  the  thickness  of  the  broad  ligament, 
between  the  outer  extremity  of  the  ovary  and  the  last  convolution  of 
the  Fallopian  tube.  (See  Fig.  2,  p.  21.)  It  is  a  small  tubular  organ  to 
which  Kobelt^  gave  the  name  of  parovarium.  It  has  been  described 
with  great  care  by  M.  Follin.^  It  is  seen  M^hen  the  broad  ligament  is 
put  on  the  stretch  and  held  up  to  the  light ;  but  is  made  out  more 
clearly  by  removing  the  thin  peritoneal  lamina  which  covers  it.  It  is 
situated  in  front  of  the  ovarian  vessels ;  it  is  of  triangular  shape,  the 
summit  directed  towards  the  ovary.  It  is  generally  composed  of  fifteen 
to  twenty  small  tubes,  slightly  flexuous,  of  unequal  length,  from  0.12 
in.  to  0.20  in.  in  diameter,  and  separated  fi-om  each  other  by  a  variable 

'  "  Der  Nebenstock  des  Weibes."     Heidelberg.     1847. 

2  "  Eecherches  sur  les  Corps  de  Wolff."     These  inaug.  Paris,  1850. 


FALLOPIAN    TUBES.  29 

space.  In  the  adult  woman  this  collection  of  tubes  is  attached  to  the 
outer  half  of  the  ovary ;  in  the  foetus  at  term,  it  corresponds  to  the 
upper  border  of  this  gland.  One  tube,  that  which  occupies  the  upper 
border  of  the  body  of  Rosenmiiller,  is  distinguished  from  the  rest  as 
performing  the  part  of  a  common  excretory  duct.  In  its  middle  it  lies 
transversely ;  its  two  ends  bend  downwards  at  right  angles,  and  are 
directed  towards  the  upper  border  of  the  ovary.  The  other  tubes  spring 
perpendicularly  from  the  transverse  portion  of  the  marginal  tube,  and 
converge  slightly  towards  the  ovary.  In  this  course  they  are  flexuous, 
of  unequal  calibre,  and  sometimes  the  seat  of  cystic  or  hydatidiform 
enlargements.  Their  ovarian  extremity  ends  in  a  cul-de-sac.  The 
wall  of  these  tubes  is  composed  of  an  outer  investment  formed  of  an- 
nular fibres ;  and  of  an  inner  tunic,  having  longitudinal  fibres,  and 
lined  in  its  interior  with  a  layer  of  vibratile  epithelium.  As  an  ap- 
pendage to  the  organ  of  "Rosenmiiller,  we  must  mention  a  vesicle  more 
or  less  pedunculated,  situated  at  the  outer  extremity  of  the  broad  liga- 
ment, and  often  adhering  to  one  of  the  fringes  of  the  pavilion  of  the 
Fallopian  tube.  This  is  the  analogue  of  the  vesicle  of  Morgagni  in 
man.  M.  Follin  has  searched  the  broad  ligament  in  order  to  find 
something  analogous  to  the  duct  of  Gaertner  which  is  seen  in  some 
animals ;  but,  like  De  Blainville,  he  has  seen  nothing  resembling  that 
which  has  been  described  by  A.  C.  Baudelocque,  Gardien,  and  others. 
It  appears  to  be  established  that  the  organ  of  Rosenmiiller  is  the 
remains  of  the  Wolffian  body,  a  transitory  organ  which  very  prob- 
ably fulfils  the  functions  of  the  kidney  before  the  development  of  this 
gland. 


CHAPTER  II. 

THE  FALLOPIAN  TUBES. 

The  Fallopian  or  uterine  tubes  are  truly  oviducts.  They  are,  in  fact, 
the  excretory  ducts  of  the  ovaries,  differing,  however,  from  all  other 
excretory  ducts  in  being  entirely  detached  from  their  proper  glands. 
They  are  situated  in  the  thickness  of  the  broad  ligaments,  and  extend 
from  the  superior  angles  of  the  uterus  to  the  sides  of  the  cavity  of  the 
pelvis.  Floating  in  the  pelvis  between  the  ovaries  which  are  behind, 
and  the  round  ligaments  which  are  in  front,  the  tubes  occupy  the 
middle  wing  of  the  broad  ligaments,  of  which  they  form  the  upper 
border ;  they  run  at  first  transversely  outwards,  and,  just  before  termi- 


30  ANATOMY. 

nating,  bend  downwards,  backwards  and  inwards,  to  approach  the 
outer  end  of  the  ovary,  to  which  they  are  connected  by  a  remarkable 
prolongation,  (See  Fig.  3,  p.  21.)  For  the  inner  half  of  their  course 
they  are  nearly  straight,  but  usually  describe  in  the  rest  of  their  length 
great  flexuosities  resembling  the  sinuous  disposition  of  that  part  of  the 
vas  deferens  which  is  nearest  the  epididymis.  The  broad  ligament 
serves  as  a  long  mesentery  to  the  oviduct,  allowing  it  to  perform  very 
extensive  movements.  It  is  not  rare  to  find  the  tube  doubled  up,  either 
before  or  behind,  and  bound  down  by  pathological  adhesions.  These 
accidental  adhesions  give  to  the  pavilion  of  the  tube  a  direction  alto- 
gether different  from  the  normal  one.  The  tubes  may  be  dragged  into 
a  hernia  with  the  ovaries.  And  the  uterus  cannot  change  its  position 
without  drawing  at  least  the  inner  end  of  the  tube  along  with  it.  From 
its  form  the  tube  was  likened  by  Fallopius  to  a  trumpet ;  it  begins 
from  the  uterus  as  a  canal  of  extremely  fine  bore  (see  Fig.  3,  p.  21), 
gradually  enlarges,  and  ends  by  an  extremity  opening  out  like  a 
funnel,  named  the  pavilion  of  the  trumpet.  The  internal  orifice,  very 
narrow,  leads  into  the  uterine  cavity  ;  the  outer  orifice  opens  into  the 
peritoneal  cavity,  and  here  presents  the  solitary  example  in  the  human 
organism  of  a  direct  communication  between  a  mucous  and  a  serous 
cavity.  Around  this  free  orifice,  which  is  a  little  more  contracted  than 
the  portion  of  tube  immediately  behind  it,  the  pavilion  is  developed. 
This  is  a  membranous  prolongation  surrounding  the  orifice  as  the 
corolla  of  a  flower  surrounds  the  stamens  and  pistils ;  it  is  cut  or 
divided  into  fringes  or  irregular  and  folded  festoons,  whence  the  name 
oi fimbriated  extremity,  or  the  quaint  metaphorical  designation  of  morsus 
diaboli.  The  largest  of  the  fimbriae  are  themselves  subdivided  or 
notched  into  smaller  fimbrise.  To  see  this  disposition  well  the  tube 
must  be  plunged  into  water.  The  inner  surface  of  the  fimbriae  pre- 
sents longitudinal  or  oblique  folds,  very  prominent,  and  which  are  pro- 
longed into  the  interior  of  the  oviduct.  The  number  and  dimensions 
of  the  fimbriae  are  very  variable ;  sometimes  they  scarcely  exist :  then 
the  edge  of  the  pavilion  looks  simply  festooned ;  sometimes  they  are 
very  large,  measuring  as  much  as  an  inch  in  length,  and  are  so  numer- 
ous as  to  quite  conceal  the  mouth  of  the  oviduct.  Often  the  base 
of  the  fimbriae  is  pierced  with  holes.  One  fimbria  is  especially  re- 
markable by  its  size ;  it  constitutes  the  posterior  part  of  the  corolla, 
and  numerous  secondary  fimbriae  are  developed  on  its  borders.  It  is 
turned  down  from  within  outwards,  and  is  supported  by  a  small  liga- 
ment— the  tuho-ovarian  ligament — which  extends  from  the  pavilion  to 
the  outer  extremity  of  the  ovary,  fixing  the  one  to  the  other.  A 
curious  arrangement,  described  by  Deville,  is  that  this  long  and  broad 
fringe  is  doubled  up  to  form  a  channel  open  below  and  behind.  Ac- 
cording to  Richard,  the  tubo-ovarian  fringe  is  not  constant.  The  ovi- 
duct may  be  divided  into  three  portions :  that  which  is  contained  within 
the  uterine  wall ;  the  free  portion  or  body  of  the  tube,  and  the  pavilion. 
The  intra-uterine  portion  is  about  00.4  inch  long;  it  is  straight,  or 
describes  a  slight  curve  with  an  inferior  concavity.  Its  cavity  is  uni- 
form and  very  narrow;  it  prolongs  outwardly  the  kind  of  horn  or 
funnel,  which  tlie  uterine  cavity  presents  at  its  upper  part,  on  either 


FALLOPIAN    TUBES.  31 

side.  The  orifice  of  communication  between  the  uterus  and  the  tube — 
ostium  uterinum — is  usually  filled  with  thick  mucus,  which  prevents 
liquid  injected  into  the  uterine  cavity  from  passing  into  the  cavity  of 
the  peritoneum.  It  forms  a  well-defined  boundary  between  the  uterine 
and  the  tubal  mucous  membrane.  The  first  is  smooth,  polished,  rosy, 
and  pierced  with  numerous  glandular  openings;  the  second  is  pale, 
white,  and  folded  in  its  longitudinal  direction. 

The  body  of  the  oviduct  springs  from  the  summit  of  the  superior 
angle  of  the  uterus,  and  is  immediately  embraced  in  the  middle  wing 
of  the  broad  ligament ;  it  is  straight  at  its  origin  for  about  two  inches ; 
it  then  forms  curves  variable  in  degree  and  number,  generally  the 
more  marked  in  proportion  to  the  youth  of  the  subject.  These  con- 
volutions are  independent  of  the  peritoneal  investment;  they  persist, 
even  when  the  tube  is  inflated  after  being  stripped.  The  inner  or  rec- 
tilineal portion  of  the  tube  is  narrower  than  the  outer  or  undulating 
portion.  The  first,  sometimes  called  the  isthmus,  has  a  diameter  of 
0.8  in.  to  0.12  in.;  the  second,  which  Henle  calls  the  "ampoule,"  is 
slightly  flattened  from  before  backwards,  and  measures  .25  in.  to  .30 
in.  in  diameter  or  more.  Often  it  narrows  a  little  near  its  termination. 
The  transition  between  the  two  portions  is  commonly  very  abrupt. 
The  most  external  convolution  of  the  tube  presents  a  very  constant 
arrangement;  its  convexity  is  directed  upwards  and  outwards:  in  other 
words,  the  peripheral  extremity  of  the  oviduct  is  turned  at  first  down- 
wards, then  backwards,  so  that  the  abdominal  orifice  looks  backwards 
and  downwards.  Whilst  the  inner  portion  of  the  tube  is  scarcely  large 
enough  to  admit  a  hog's  bristle,  the  outer  portion  receives  easily  the 
extremity  of  a  moderately-sized  sound.  The  walls  of  the  oviduct  are 
in  contact,  and  the  cavity,  completely  obliterated,  presents  on  trans- 
verse section  the  figure  of  a  star,  the  rays  of  which  penetrate  between 
the  numerous  longitudinal  folds  of  the  mucous  membrane.  In  the 
uterine  portion  of  the  tube  the  bore  is  capillary,  and  it  is  only  with 
great  trouble  that  one  succeeds  in  seeing  the  ostium  uterinum  with  the 
naked  eye.  The  tube  expanding  on  the  one  side  into  the  cavity  of  the 
uterus,  and  on  the  other  into  that  of  the  peritoneum,  it  follows  that  the 
two  cavities  communicate,  a  disposition  which  has  favored  the  develop- 
ment of  peritonitis  by  permitting  the  passage  of  irritating  matters  from 
the  uterus  along  the  tubes  into  the  peritoneal  cavity.  It  is  not  rare  to 
find  the  abdominal  orifice  obliterated.  In  such  cases  the  tube  is  dilated 
in  the  form  of  a  cone,  with  its  base  directed  outwardly ;  its  inflexions 
then  become  very  marked.  The  whole  inner  surface  of  the  oviduct  is 
of  a  pale  pink  color,  and  is  marked  by  longitudinal  folds  of  unequal 
sizes,  which  touch  by  their  surfaces,  converting  the  channel  of  the  tube 
into  a  series  of  capillary  tubes.  These  folds,  always  parallel  to  the 
axis  of  the  tube,  begin  in  the  intra-uterine  portion  by  two  or  three 
small  ridges,  and  become  more  numerous  and  prominent  at  the  inner 
portion  of  the  body  of  the  tube,  and  are  developed  to  the  greatest  extent 
in  the  expanded  portion  of  the  canal.  (See  Fig.  3,  p.  21.)  They  project 
in  variable  degree :  some  scarcely  rise  above  the  level  of  the  mucous 
membrane;  others  are  0.9  in.  in  height.  On  transverse  section  they 
sometimes  resemble  csecal  glands ;  at  others,  arborescent  villosities.    In 


32  ANATOMY, 

the  latter  case,  the  principal  folds  are  provided  on  both  surfaces  with 
secondary  folds,  which  themselves  may  be  covered  with  tertiary  folds. 
Often,  also,  the  surface  of  the  folds  present  linear  reliefs,  like  project- 
ing ridges,  united  together,  and  inclosing  irregular  spaces  or  pits.  'No 
valves  are  met  with  either  in  the  course  or  orifice  of  the  oviduct. 

In  its  narrow  portion  the  tube  is  firm  to  the  touch,  inextensible,  and 
much  resembles  the  vas  deferens ;  in  its  large  portion  it  is  collapsed 
upon  itself,  and  its  walls  are  thin  and  extensible.  Richard  has  ob- 
served an  interesting  feature  in  the  history  of  the  oviducts.  It  is  not 
very  rare  to  meet  on  the  surface  one  or  two  small  supernumerary  pavil- 
ions, formed  like  the  terminal  pavilion  by  the  mucous  membrane  of 
the  tube  cut  up  into  fringes,  and  pierced  by  a  hole  opening  into  the 
canal. 

The  tube  is  composed  of  three  coats :  an  external,  or  serous ;  a  middle, 
or  muscular;  and  an  inner  or  mucous  coat.  The  peritoneum  supplies 
the  serous  tunic,  which  adheres  but  loosely  to  the  tube,  and  only  sur- 
rounds three-quarters  of  its  circumference.  The  adhesion  becomes 
closer  at  the  level  of  the  pavilion,  the  peritoneum  of  which  clothes  the 
outer  surface,  and  is  continuous  with  the  mucous  membrane  at  the  free 
edge  of  the  fringes.  In  the  very  loose  cellular  tissue  which  unites  the 
serous  coat  to  the  muscular  coat,  small  longitudinal  muscular  bundles 
are  sometimes  met  with.  The  muscular  coat  of  the  oviduct  forms  a 
white  membrane  of  dense  and  close  texture.  Richard  and  Robin  have 
doubted  the  muscular  character  of  the  middle  coat.  It  is  affirmed, 
however,  by  Kolliker.  Dr.  Arthur  Farre  has  found  well-marked, 
smooth,  muscular  fibres  in  the  genera,  Simia,  Bos,  Cervus,  and  in  the 
pregnant  dolphin,  and  also  in  the  human  female  during  middle  life. 
It  is  composed  chiefly  of  annular  fibres :  on  its  surface  some  bundles  of 
longitudinal  muscular  fibres,  which  seem  to  proceed  from  the  muscular 
fibres  of  the  uterus,  are  attached.  Where  the  tube  traverses  the  uterine 
wall,  the  muscular  coat  of  tlie  oviduct  preserves  its  own  character  quite 
distinct  from  that  of  the  uterus.  The  mucous  coat,  which  alone  forms 
the  numerous  folds  of  the  inner  surface  of  the  oviduct,  presents  o.  funda- 
mental stratum  formed  by  connective  tissues  and  longitudinal  muscular 
fibres,  and  by  a  vibratile  or  ciliated  epithelmm.  It  contains  neither 
glands  nor  villi.  The  cilia  which  cover  the  free  surface  of  the  cells 
execute  movements  the  effect  of  which  is  to  carry  on  liquids  and  the 
ovum  to  the  uterine  cavity.  This  is  one  function  of  the  tube;  the 
other  is  to  receive  and  transmit  towards  the  ovary  the  fecundating 
principle  of  the  male.  If  the  tubes  are  closed  by  ligature  or  by  disease 
sterility  is  the  consequence.  The  ovum  may  be  fecundated  and  arrested 
in  the  tube,  and  be  developed  there,  constituting  tubal  gestation.  The 
pavilion  of  the  tube  is  charged  with  the  duty  of  embracing  the  ovary 
at  the  moment  of  dehiscence  of  the  Graafian  follicle,  and  of  applying 
itself  closely  to  the  point  whence  the  ovum  detaches  itself.  Hence  it 
follows  that  any  adhesion  of  the  ovary  or  of  the  tube  which  prevents 
this  relation  is  a  cause  of  sterility.  The  Fallopian  tubes,  like  the 
uterus  and  vagina,  result  from  the  development  of  the  canals  of  Miiller, 
which  stretch  over  the  surface  of  the  Wolffian  bodies,  with  which  they 
have  no  connection,  and  terminate  at  the  pedicle  of  the  allantois,  unit- 


THE     UTERUS. 


33 


ing  together  in  the  median  line.  At  first,  the  uterine  tubes  are  rela- 
tively more  developed  than  the  body  of  the  uterus ;  so  much  so  that 
they  seem  to  be  continuous  one  with  the  other  at  their  uterine  ends. 
They  preserve  this  relative  development  until  the  epoch  of  puberty. 
The  uterine  tubes  are  much  more  flexuous  during  the  last  two  months 
of  intra-uterine  life  than  at  any  later  period. 

THE   UTERUS. 

The  Uterus  {utriculus,  a  bag)  is  the  organ  of  gestation  and  of  partu- 
rition. It  is  a  hollow  organ  possessing  thick  muscular  walls,  destined 
to  receive  the  fecundated  ovum,  to  supply  to  it  the  materials  necessary 
for  its  development,  and  to  expel  it  when  mature. 


Fig  8 


Longitudinal  section  of  the  pelvis — (after  Breisky). 

The  uterus  is  situated  in  the  cavity  of  the  pelvis,  in  the  median  line 
between  the  bladder  and  the  rectum,  beneath  the  mass  of  intestines, 
and  above  the  vagina  (see  Fig.  8).  It  is  held  in  its  position  slung  or 
suspended  by  different  folds  of  the  peritoneum  and  by  muscular  bun- 
dles, principally  situated  in  these  folds.  Closely  connected  also  with 
the  bladder,  Fallopian  tubes,  rectum,  and  vagina,  these  structures  all 
concur  in  maintaining  the  position  of  the  uterus.  The  ligaments  of  the 
uterus  are  six  in  number,  three  on  each  side ;  namely,  the  broad  liga- 
ments, the  round  ligaments,  and  the  utero-sacral  ligaments  (see  Fig.  1, 
p.  19).     The  broad  ligaments  are  two  folds,  formed  by  the  peritoneum, 

3 


34  THE    UTERUS. 

and  stretched  across  the  cavity  of  the  pelvis,  extending  from  the  borders 
of  the  uterus  to  the  sides  of  the  pelvis,  and  thus,  with  the  uterus  sus- 
pended between  them,  forming  a  septum  which  divides  the  pelvis  into 
two  parts.  The  broad  ligaments  are  of  quadrangular  form,  their  inner 
border  is  attached  to  the  border  of  the  uterus,  or  more  correctly  speak- 
ing, the  two  laminse  which  form  them  separate  to  receive  the  uterus  in 
the  space  between  them.  It  is  to  be  remarked  that  the  broad  ligaments 
are  attached  on  a  level  with  the  anterior  aspect  of  the  uterus,  so  that 
the  Avhole  thickness  of  the  uterus  lies  behind  the  ligaments.  Their 
external  border  is  continuous  with  the  peritoneum  which  lines  the  pelvic 
cavity.  At  the  level  of  their  inferior  border  the  two  laminae  of  the 
broad  ligament  separate  to  line  the  floor  of  the  pelvis ;  a  loose  cellular 
tissue,  including  very  little  fat,  is  interposed  at  this  level  between  the 
laminae,  and  unites  them  to  the  superior  pelvic  fascia.  This  cellular 
tissue  is  directly  continuous  with  that  which  is  found  on  the  sides  of 
the  vagina  and  rectum  below,  in  the  iliac  fossa  laterally,  and  around 
the  bladder  in  front ;  it  also  communicates  through  the  sciatic  notch 
with  the  deep  cellular  tissue  of  the  nates.  This  disposition  is  of  im- 
portance to  bear  in  mind  in  the  study  of  the  collections  of  blood  and 
pus  which  may  form  in  this  region.  The  upper  border  of  the  broad 
ligaments  is  divided  on  either  side  into  three  secondary  folds,  formed, 
the  posterior  one  by  the  ovary  and  its  ligament,  the  anterior  one  by  the 
round  ligament,  and  the  third  or  middle  one  by  the  Fallopian  tube.  It 
is  this  arrangement  which  has  caused  the  broad  ligament  to  be  likened 
to  the  wing  of  the  bat  {ala  vespertilionis).  (See  Figs.  1  and  3.)  The 
middle  fold  or  winglet  is  the  largest  and  the  highest,  and  constitutes 
the  true  upper  border  of  the  broad  ligaments.  These  ligaments  are 
formed  of  two  peritoneal  laminae  and  by  an  intermediate  layer  of  cel- 
lular tissue,  in  which  run  the  numerous  vessels  and  nerves  belonging 
to  the  uterus  and  ovary,  as  well  as  a  multitude  of  muscular  fibres 
springing  from  the  uterus.  They  also  inclose  the  remains  of  the 
Wolffian  body  or  organ  of  Rosenmiiller.  The  muscular  fibres  of  the 
broad  ligament,  according  to  M.  Rouget,  all  rise  from  the  sides  of  the 
uterus,  and  are  directed  towards  the  wall  of  the  pelvis.  They  do  not 
form  a  continuous  layer,  but  their  bundles  of  various  sizes  form  a  kind 
of  lace- work  or  open  canvas,  mixed'  with  the  vascular  and  nervous  net- 
works, the  whole  covered  and  masked  by  connective  tissue.  M.  Rouget 
describes  the  uterus  and  its  appendages  as  being  inclosed  in  a  broad 
muscular  membrane,  of  which  the  peritoneal  ligaments  are  a  depend- 
ency. The  broad  ligaments  do  not  prevent  the  uterus  from  inclining 
backwards  or  forwards.  M.  Richet  says  they  oppose  flexions  of  the 
body  on  the  neck.  Although  never  fully  on  the  stretch,  they  resist 
lateral  deviations  of  the  uterus.  They  allow  the  uterus  to  be  sensi- 
bly lowered  without  being  dragged. 

The  structure  of  the  round  ligament  has  been  carefully  examined  by 
Mr.  Rainey.^  He  says  it  is  a  muscle  rather  than  a  ligament,  and  he 
has  shown  that  it  consists  principally  of  striped  or  voluntary  nniscle. 
It  arises  by  three  fasciculi  of  tendinous  fibres  ;  the  inner  one  from  the 

'  Philosophical  Transactions,  1850. 


THE    ROUND    LIGAMENTS.  35 

tendon  of  the  internal  oblique  and  transversalis  muscle  near  to  the 
symphysis  pubis,  the  middle  one  from  the  superior  column  of  the  ex- 
ternal abdominal  ring,  near  to  its  upper  part,  and  the  external  fasciculus 
from  the  inferior  column  of  the  ring  just  above  Gimbernat's  ligament. 
From  these  attachments  the  fibres  pass  backwards  and  outwards,  soon 
becoming  fleshy;  they  then  unite  into  a  rounded  cord,  which  crosses 
in  front  of  the  epigastric  artery  and  behind  the  lower  border  of  the 
internal  oblique  and  transversalis  muscles ;  it  then  gets  between  the 
layers  of  the  peritoneum  forming  the  broad  ligament,  along  which  it 
passes  backwards,  downwards,  and  inwards  to  the  anterior  and  suJDe- 
rior  part  of  the  uterus,  into  which  its  fibres,  spreading  out  a  little,  may 
be  said  to  be  inserted. 

The  striated  muscular  fibres  are  not  confined  to  the  surface  of  the 
round  ligament,  but  form  almost  the  whole  of  its  substance,  and  are 
more  particularly  distinct  near  to  its  centre;  nor  do  they  extend  com- 
pletely to  the  uterus,  but  after  passing  between  the  layers  of  the  broad 
ligament  to  about  an  inch  or  an  inch  and  a  half  from  its  superior  part, 
they  gradually  lose  their  striated  character,  and  degenerate  into  fascic- 
uli of  granular  fibres  mixed  with  long  threads  of  fibro-cellular  tissue. 

Mr.  Rainey  found  a  similar  structure  in  the  monkey,  dog,  sheep, 
and  cow.  The  round  ligaments  contain  also  numerous  vessels,  also 
some  nerves  and  absorbents.  The  arterial  trunks  are  large,  but 
the  capillaries  into  which  they  ultimately  divide  have  the  same  size 
and  arrangement  as  those  of  ordinary  muscle.  The  lymphatics  are 
situated  on  the  outer  side  of  the  ligament;  their  glands  are  sometimes 
of  considerable  length,  and  even  pass  through  the  external  abdominal 
ring ;  connecting  all  these  parts  together  there  is  a  considerable  quan- 
tity of  areolar  tissue,  especially  where  the  striated  muscular  fibres  are 
absent,  or  are  about  to  terminate. 

Mr.  Rainey,  reasoning  from  the  structure  of  the  round  ligaments, 
says  the  presence  of  voluntary  muscular  fibre  proves  that  they  are  not 
fitted  to  serve  as  mechanical  supports  to  the  uterus ;  but  that  their  real 
use  is  in  some  way  or  other  to  act  in  copulation.  Considering  the 
position  of  their  points  of  attachment  and  the  direction  of  their  fibres, 
it  is  evident  that  their  combined  action  will  bring  the  uterus  nearer  to 
the  symphysis  pubis,  and  thus  tend  to  draw  it  somewhat  from  the 
vagina,  in  this  way  increasing  the  length  of  the  latter.  Now  the  only 
way  in  which  it  can  be  imagined  that  these  changes  assist  in  sexual 
intercourse,  is  by  their  causing  the  semen  to  be  attracted  into  the  upper 
part  of  the  vagina  and  vicinity  of  the  os  uteri.  This  opinion,  as  to 
the  use  of  the  round  ligaments,  had  been  enunciated  by  Velpeau  and 
Maygrier. 

The  round  ligament  also  contains  a  great  number  of  vessels,  espe- 
cially veins,  which  may  become  varicose,  says  Cruveilhier,  particularly 
at  the  level  of  the  external  orifice  of  the  inguinal  canal,  where  they 
have  sometimes  simulated  a  hernia.  In  the  foetus,  and  occasionally 
even  after  birth,  the  round  ligaments  are  accompanied  in  the  inguinal 
canal  by  a  prolongation  of  the  peritoneum,  quite  analogous  to  that 
which  accompanies  the  spermatic  cord.  This  diverticulum,  known 
under  the  name  of  the  canal  of  Nuck,  sooner  or  later  becomes  obliter- 


36  THE    MOVEMENTS    OF    THE     UTERUS. 

ated.  But  sometimes  this  obliteration  does  not  take  place,  and  this 
explains  the  frequency  of  inguinal  hernia  in  women.  The  round  liga- 
ments are  never  on  the  stretch,  and  cannot  resist  displacements  of  the 
uterus. 

The  anterior  or  utero-vesical  ligaments  are  two  lateral  folds  of  peri- 
toneum, containing  bundles  of  fibrous  tissue.  They  are  found  where 
the  peritoneum  is  reflected  forwards  on  to  the  bladder,  opposite  the 
point  of  junction  of  the  body  and  neck  of  the  uterus,  and  from  the 
lateral  boundaries  of  the  utero-vesical  peritoneal  pouch. 

The  posterioi'  or  utero-sacral  ligaments  extend  from  the  lower  part  of 
the  body  of  the  uterus  to  the  outer  sides  of  the  sacrum,  enveloped  by 
■peritoneum ;  they  form  two  semilunar  or  falciform  folds — the  folds  of 
Douglas ;  their  inner  borders  are  concave  and  sharp,  and  pass  on  to  the 
.sides  of  the  rectum,  forming  an  oval  opening,  which  leads  to  a  cavity 
formed  by  the  recto-vaginal  depression  of  the  peritoneum.  These 
ligaments,  and  the  pouch  between  them  (Douglas's  sac),  are  well  seen 
when  the  uterus  is  drawn  forwards.  The  utero-sacral  ligaments  are 
composed  of  smooth,  muscular  fibres,  which  spring  from  the  uterus, 
and  of  a  peritoneal  investment.  The  experiments  of  Malgaigne  seem 
to  demonstrate  that  these  ligaments  constitute  the  princif>al  obstacle  to 
the  falling  of  the  womb  towards  the  vulva.  When  traction  is  made 
upon  the  cervix  uteri,  these  ligaments  are  immediately  seen  to  be  tight- 
ened ;  when  divided,  the  uterus  sensibly  drops,  but  is  soon  arrested  by 
the  broad  ligaments  and  the  resistance  of  the  floor  of  the  pelvis,  chiefly 
by  the  floor  of  the  peritoneum,  which  is  reflected  from  the  walls  of  the 
pelvis  over  the  bladder,  uterus,  and  rectum.  M.  Richet  believes  that 
the  utero-sacral  ligaments  further  serve  to  prevent  the  uteras  from  being 
driven  forwards  upon  the  bladder,  thus  preserving  this  organ  from  the 
severe  compression  to  which  it  would  otherwise  be  subjected. 

The  extent  and  directions  of  movement  of  which  the  uterus  is  capa- 
ble form  an  important  subject  of  study.  The  first  question  to  determine 
is,  AYhat  is  the  normal  position  of  the  uterus  ?  A  line  drawn  from  the 
upper  margin  of  the  symphysis  pubis  to  the  lumbo-sacral  articulation 
will  strike  the  upper  margin  of  the  fundus  of  the  uterus.  Another 
line  drawn  from  the  lower  border  of  the  symphysis  pubis  to  the  lower 
margin  of  the  fourth  sacral  vertebra,  will  touch  at  its  middle  the  point 
of  the  cervix  (see  Fig.  8). 

The  movements  of  the  uterus  are  limited  by  its  connections,  and  are 
influenced  by  the  changes  of  condition  of  the  surrounding  organs.  The 
greatest  amount  of  mobility  is  enjoyed  by  the  fundus.  The  cervix, 
being  bound  to  the  bladder  and  vagina,  enjoys  a  more  limited  amount 
of  motion.  The  fundus  may  be  thrown  backwards  or  forwards,  and 
thus  acting  as  a  lever  it  will  throw  the  os  in  the  opposite  direction. 
The  fundus  does  not  move  round  the  os  exactly  as  upon  a  pivot,  but 
the  os  is  projected  a  little  forwards  or  backwards  whenever  the  fundus 
moves  in  the  opposite  direction.  Distension  of  the  bladder  will  throw 
the  fundus  backwards  ;  loading  of  the  rectum  will  ])ress  the  fundus 
forwards  and  downwards.  In  retroversion  of  the  fundus  of  the  uterus, 
enlarged  by  gestation  or  other  causes,  the  cervix  may  be  driven  so  firmly 
against  the  symphysis  pubis  as  to  close  the  urethra ;  and  as  the  base  of 


THE  MOVEMENTS  OF  THE  UTERUS.  37 

the  bladder  to  which  the  cervix  uteri  is  attached  has  a  certain  amount 
of  mobility,  in  anteversion  of  the  body  of  the  uterus,  the  cervix  may 
be  carried  back  close  to  the  promontory  of  the  sacrum,  dragging  the 
attached  wall  of  the  bladder  with  it.  But  the  upward  mobility  of  the 
part  of  the  bladder  to  which  the  cervix  is  united  is  limited ;  hence  it 
happens  that  when  the  fundus  is  thrown  backwards  the  cervix,  held 
down  in  some  degree  by  its  vesical  attachments,  becomes  bent,  so  that 
the  OS  looks  downwards,  instead  of  being  projected  forwards  exactly  in 
a  line  with  the  axis  of  the  fundus. 

There  is  one  condition  in  which  the  whole  uterus  is  driven  forwards 
closely  behind  the  pubes.  This  is  when  a  considerable  accumulation 
of  blood  takes  place  in  Douglas's  pouch.  In  this  case — retro-uterine 
hsematocele — the  collected  blood  behind  the  uterus  may  be  felt  as  a 
tumor  projecting  in  the  fundus  of  the  vagina,  and  also  by  the  rectum. 

In  addition  to  the  backward  and  forward  or  see-saw  movement,  the 
uterus  may  move  to  either  side.  Here  again  it  is  the  fundus  especially 
that  is  displaced.  These  lateral  movements  are  restricted  somewhat  by 
the  broad  ligaments.  It  must,  however,  be  remembered  that  there 
exists  commonly  a  certain  lateral  obliquity.  Tlie  fundus  is  generally 
inclined  a  little  to  the  leftside;  and  this  left  lateral  obliquity  is  usually 
increased  during  pregnancy.  It  may  be  due  to  the  situation  of  the 
rectum  in  the  left  side  of  the  pelvis. 

Another  movement  is  upwards  or  downwards.  The  pressure  of  the 
abdominal  viscera  may  carry  down  the  entire  mass  of  the  pelvic  viscera 
towards  the  perineum,  or  the  uterus  may  be  elevated  slightly  by  up- 
ward pressure  on  the  cervix. 

Some  amount  of  alternate  elevation  and  depression  of  the  uterus 
takes  place  normally,  under  the  influence  of  respiration  and  of  volun- 
tary muscular  exertion.  On  inspiration,  the  entire  mass  of  abdominal 
viscera  is  forced  downwards,  pressing  the  uterus  before  it.  On  expira- 
tion there  is  a  general  movement  of  collapse  towards  the  centre  of  the 
body,  under  the  influence  of  atmospheric  pressure.  This,  of  course, 
bears  most  directly  upon  the  external  soft  parts.  The  perineum  and 
vulva  are  pressed  inwards,  and  the  uterus  rises  towards  the  abdomen. 
Under  the  influence  of  defecation,  again,  or  of  any  powerful  muscular 
exertion  in  which  the  chest-walls  are  fixed,  the  uterus  is  driven  down- 
wards ;  sometimes,  indeed,  so  violently  that  complete  prolapsus  has 
been  thus  induced.  I  have  known  complete  prolapsus  of  the  uterus 
occur  in  a  virgin,  under  the  violent  efibrts  of  epileptic  convulsions. 
The  descent  of  the  uterus,  anterior  wall  of  the  vagina,  and  base  of  the 
bladder,  is  very  obvious,  if  vomiting  or  coughing  occur  during  an  ex- 
amination by  speculum.  The  instrument  is  easily  driven  out,  as  the 
OS  uteri  is  often  brought  quite  down  to  the  vulva.  This  observation 
proves  that  the  so-called  ligaments  of  the  uterus  exert  but  a  small  in- 
fluence in  preventing  prolapsus. 

All  these  movements  may  be  verified  by  manual  examination.  By 
placing  the  tip  of  a  finger  of  one  hand  on  the  os  uteri,  as  in  examina- 
tion per  vaginam,  and  applying  pressure  upon  the  fundus,  by  the  other 
hand,  through  the  abdominal  wall  above  the  pubes,  the  cervix  may  be 


38    THE  MOVEMENTS  AND  AXIS  OF  THE  UTEEUS. 

felt  to  move  about  according  to  the  direction  of  the  pressure  applied  by 
either  hand. 

The  true  Axis  of  Movement  of  the  Uterus. — The  centre  around  which 
the  chief  movements  take  place  is,  of  course,  its  most  fixed  point. 
This  is  the  anterior  part  of  the  supra-vaginal  portion  of  the  cervix, 
which  is  closely  connected  with  the  base  of  the  bladder  (see  Fig.  8, 
Breisky's  section,  p.  33).  At  this  part  the  uterus  is  held,  whilst  its 
two  extremities,  body  and  vaginal  portion,  are  free.  Hence  the  move- 
ments of  which  the  uterus  is  capable  are  relative  and  general.  The 
first  order  of  movements  are  those  in  which  the  uterus  inclines  back- 
wards or  forwards,  or  to  either  side.  The  second  order,  or  those  in 
which  the  uterus  moves  upwards  and  downwards,  can  only  be  accom- 
plished simultaneously  with  corresponding  movements  of  the  base  of 
the  bladder.  The  organs  move  en  masse,  preserving  more  or  less  com- 
pletely their  relative  positions,  as  when  the  rectum  is  distended  by  fecal 
accumulations,  or,  when  empty,  it  retreats. 

The  Direction  of  the  Uterus. — The  longitudinal  axis  is  directed  ob- 
liquely from  above  downwards,  and  from  before  backwards ;  that  is,  it 
is  nearly  coincident  with  the  axis  of  the  brim  of  the  pelvis,  and  forms 
with  the  axis  of  the  vagina  an  obtuse  angle.  It  follows  that  the  fundus 
of  the  uterus  looks  upwards  and  forwards,  its  apex,  or  the  os,  back- 
wards and  downwards  (see  Fig.  8).  This,  the  normal  direction,  is, 
however,  subject  to  variations,  which  cannot  be  always  regarded  as  of 
pathological  significance. 

As  a  general  fact,  it  is  to  be  observed  that  the  connections  of  the 
uterus  are  loose  and  extensile,  and  permit  the  organ  to  float  in  the 
cavity  of  the  pelvis,  performing  more  or  less  extensive  movements. 
The  ease  with  which  the  uterus  can  be  drawn  down  towards  the  vulva 
in  certain  surgical  oj^erations,  and  the  displacement  which  it  undergoes 
during  pregnancy,  when  it  rises  into  the  abdomen,  are  proofs  of  its 
great  mobility.  This  property  is  turned  to  account  to  facilitate  ex- 
ploration, and  the  detachment  of  the  ovum  in  cases  of  hemorrhage  in 
abortion.  For  these  purposes  strong  pressure  is  made  upon  the  fundus 
by  the  hand  applied  to  the  lower  part  of  the  abdomen. 

There  is  one  deviation  from  the  standard  axis  of  the  uterus  which 
appears  to  be  nearly  constant :  it  is  that  in  which  it  takes  an  oblique 
direction  from  right  to  left.  It  is  thought  to  depend  vipon  the  presence 
of  the  rectum  on  the  left  side  of  the  pelvis.  During  pregnancy  this 
inclination  is  much  exaggerated ;  it  corresponds  with  the  most  usual 
position  of  the  foetus,  that  in  which  the  occiput  is  directed  to  the  left 
cotyloid  cavity  of  the  mother.  MM.  Boulard,  Verneuil,  Follin,  H. 
Bennet,  Richet,  Arar,  and  others,  have  made  very  jjrecise  observations, 
which  establish  the  fact  that  the  uterine  axis  is  not  a  straight  but  a 
curved  line,  that  it  is  bent  about  the  middle,  presenting  an  anterior 
concavity.  In  introducing  the  uterine  sound  it  is  therefore  proper  to 
give  a  small  curvature  to  the  instrument,  and  to  make  the  point  de- 
scribe a  gradual  curve  forwards  after  passing  the  os  uteri  externum. 

In  the  human  subject  the  uterus  is  single ;  in  most  animals  it  is 
double.  The  so-called  double  uteri  observed  in  the  human  species  are 
in  reality  only  bifid  or  divided  uteri,  depending  upon  an  arrest  of 


THE    SIZE    AND    WEIGHT    OF    THE    UTERUS.  39 

development.  The  bifid  character  may  be  limited  to  the  body,  or  may 
extend  to  the  cervix,  and  even  to  the  vagina.  The  nterus  may  even 
be  absent.  In  one  case  I  failed,  after  the  most  minute  exploration,  to 
discover  a  trace  of  such  an  organ.  But  most  commonly,  where  dissec- 
tion has  been  instituted,  a  rudimentary  uterus  has  been  discovered  be- 
tween the  rectum  and  the  bladder. 

The  abnormal  forms  of  the  uterus  will  be  described  with  its  patho- 
logical conditions. 

The  size  of  the  uterus  varies  according  to  the  age  and  certain  physio- 
logical conditions.  It  is  very  small  before  puberty,  the  neck  predomi- 
nating over  the  body  (see  Fig.  9).  When  menstruation  sets  in  it  grows 
greatly,  and  it  enlarges  a  little  at  every  period,  returning  during  the 
intervals  to  the  ordinary  size.  Pregnancy  exerts  a  more  durable  in- 
fluence ;  after  delivery  the  uterus  commonly  retains  an  increased  bulk. 
In  old  age  the  uterus  shrinks,  so  that  it  is  sometimes  reduced  to  the 
size  presented  in  new-born  children. 


uterus  and  appendages  of  an  infant — (after  A.  Farre). 

a,  cavity  of  body  laid  open;  6,  cavity  of  cervix ;  c,  anterior  lip  of  the  cervix  ;  d,  left  ovary  opened  ; 
e,  Fallopian  tube  ;  /,  right  ovary  ;  ff,  internal  os  uteri,  marking  the  division  between  the  body  and 
cervix. 

The  development  of  the  uterus  is  sometimes  imperfect.  It  may  re- 
tain the  dimensions  and  other  characters  of  immaturity.  This  imper- 
fection may  bear  upon  the  body  or  upon  the  cervix.  In  the  latter  case, 
the  part  which  projects  into  the  vagina  is  often  more  conoid  than  natu- 
ral, and  the  os  externum  is  a  very  small  round  opening  which  barely 
admits  the  uterine  sound.  In  these  cases  there  is  also  commonly  pres- 
ent a  greater  curvature  of  the  uterus,  sometimes  amounting  to  angula- 
tion at  the  union  of  the  body  and  cervix.  This  condition  is  usually 
associated  with  sterility,  dysmenorrhoea,  or  menorrhagia,  sometimes 
amenorrhcea,  and  it  may  even  lead  to  menorrhagic  eiFusions  into  the 
peritoneum,  by  opposing  the  free  natural  exit  of  the  menstrual  fluid. 

The  weight  of  the  uterus  in  girls  at  the  age  of  puberty  is  from  360 


40 


THE    DIVISIONS    OF    THE    UTERUS. 


to  1000  grains ;  from  1200  to  1800  grains,  in  women  who  have  borne 
children  ;  it  may  be  reduced  to  100  or  200  grains  in  old  women.  At 
the  term  of  gestation  it  may  weigh  from  26  ounces  to  52  ounces. 

The  shape  of  the  uterus  is  that  of  a  pear,  or  rather  of  a  cone  flat- 
tened from  before  backwards ;  it  is  divided  into  body  and  neck.  A 
narrowing,  or  isthmus,  marks  the  boundary  between  these  two  parts. 
This  isthmus  is  very  marked  in  infants ;  it  diminishes,  sensibly  at  pu- 
berty, and  is  still  more  indistinct  after  several  pregnancies.  The  vagina 
being  inserted  on  to  the  neck  of  the  uterus,  divides  it  into  a  vaginal 
portion  and  a  supra-vaginal  portion  (see  Fig.  10). 


Fig.  10. 


Fig.  11. 


Showing  the  regional  divisions  of  the  uterus — 
(after  A.  Farre). 


A'ertical  section  of  the  uterus  parallel 
with  its  lateral  border — (after 
A.  Farre). 
Fig.  10. — a,  the  fundus;  a,  a,  b,  b,  mark  the  body  of  the  uterus;  b,  b,  c,  c,  mark  the  cervix ;  6,  the 
OS  uteri.    Below  c,  c,  which  marks  the  reflection  of  the  vagina,  is  the  vaginal  portion. 

Fig.  11. — a,  anterior;^,  posterior,  lip  of  cervix  ;  i,  internal  os  uteri-  va,  vagina;/,  fornix,  or  posterior 
pouch  of  fundus  of  vagina;  c,  loose  connective  tissue  immediately  above  the  fornix  ;  r,  point  of  pos- 
terior reflection  of  the  peritoneum  on  to  the  rectum,  forming  the  retro-uterine  pouch  or  space  of 
Douglas ;  6,  6,  line  of  attachment  of  the  cervix  to  the  bladder.  The  peritoneum  ceases  at  the  upper  h 
in  front. 


To  study  the  uterus  thoroughly,  it  is  necessary  to  describe  two  sur- 
faces, the  anterior  and  the  posterior;  two  lateral  borders,  an  upper 
border  ov  fundus,  and  an  inferior  extremity,  perforated,  projecting  into 
the  vagina,  called  the  vaginal  portion  of  the  neck,  with  the  os  tinea'. 

In  its  upper  three-fourths  the  anterior  surface  is  slightly  convex, 
and  smooth  like  all  parts  covered  with  peritoneum,  and  is  in  relation 
with  the  posterior  surface  of  the  bladder,  from  which  it  is  often  sepa- 
rated by  coils  of  small  intestine.  When  the  bladder  is  full,  the  uterus 
is  pushed  away  from  the  anterior  abdominal  wall ;  hence  the  precept, 


THE    RELATIONS    OF    THE    UTERUS.  41 

always  to  empty  the  bladder  before  exploring  the  uterus  through  the 
abdomen.  In  its  lower  fourth  the  anterior  surface  of  the  uterus  is  in 
direct  relation  with  the  base  of  the  bladder,  to  which  it  is  united  by  a 
loose  cellular  tissue.  This  relation  explains  the  frequency  with  which 
cancerous  affections  of  the  uterus  spread  to  the  base  of  the  bladder. 
This  portion  of  the  pelvic  cellular  tissue  is  also  especially  liable  to  be- 
come inflamed  from  injury  received  during  labor  and  to  be  the  seat  of 
abscess  (see  Fig.  11,  6,  b). 

The  posterior  surface  of  the  uterus  is  covered  by  peritoneum  through- 
out its  whole  extent.  It  is  in  mediate  relation  with  the  anterior  sur- 
face of  the  rectum,  from  which  it  is  said  to  be  often  separated  by  folds 
of  small  intestine.  But  Claudius  of  Marburg*  says  that  in  the  living 
subject  the  uterine  sound  passed  into  the  uterus  may  always  be  felt  by 
the  finger  in  the  rectum,  showing  that  Douglas's  sac  is  not  filled  by 
intestine.  In  the  dead  subject  frozen,  the  uterus  with  its  broad  liga- 
ments and  ovaries  is  mostly  found  lying  as  close  to  the  posterior  wall 
of  the  pelvis  as  the  lungs  are  to  the  ribs.  The  rectum  passes  close  by 
the  left  border  of  the  body  of  the  uterus.  Having  examined  sections 
of  many  frozen  subjects,  he  concludes  that  there  is  always  anteversion, 
anteflexion,  or  antefraction  of  the  uterus  when  intestinal  loops  are  pres- 
ent in  Douglas's  sac.  My  own  observations  confirm  those  of  Claudius. 
The  anterior  and  posterior  walls  of  Douglas's  sac  are  always  in  close 
apposition  in  the  normal  condition. 

The  posterior  surface  is  more  convex  than  the  anterior,  and  can  be 
explored  by  the  finger  introduced  into  the  rectum. 

The  lateral  margins  of  the  uterus  are  slightly  concave,  thick,  and 
situated  between  the  two  laminse  of  the  broad  ligaments.  They  are  in 
relation  with  the  trunks  of  the  uterine  arteries,  the  venous  plexuses,  the 
nerves,  and  the  cellular  tissue  confined  within  the  thickness  of  the 
broad  ligaments.  This  cellular  tissue  is  the  frequent  seat  of  inflamma- 
tion and  abscess  after  labor. 

The  upper  border  or  fundus  is  convex,  thick,  rounded,  and  forms 
the  base  of  the  flattened  cone  which  the  uterus  represents.  Clothed 
with  peritoneum  and  covered  with  the  coils  of  the  small  intestine,  the 
fundus  of  the  empty  uterus  never  rises  to  the  level  of  the  brim  of  the 
pelvis;  it  is  therefore  only  in  the  diseased  state  or  during  pregnancy 
that  it  is  possible  to  feel  it  by  the  fingers  applied  to  the  hypogastrium. 
In  the  imparous  woman  the  upper  border  is  nearly  straight  and  on  a 
level  with  the  Fallopian  tubes ;  after  one  or  more  pregnancies,  it  always 
remains  convex,  being  more  raised  in  the  middle  than  near  the  origin 
of  the  tubes. 

The  inferior  extremity  of  the  uterus  is  the  apex  of  the  uterine  cone. 
The  OS  tincce,  or  vaginal  portion,  has  the  form  of  a  rounded  cone.  It 
usually  projects  0.25  in.  to  0.5  in.,  but  in  certain  pathological  states  it 
may  be  lengthened  so  as  to  reach  the  vulva  or  even  to  protrude  ex- 
ternally. Caseaux  says  the  length  of  the  vaginal  portion  diminishes 
in  proportion  to  the  number  of  pregnancies,  and  may  even  disappear 
altogether  in  women  who  have  had  many  children.     But  this  disap- 

1  "Med.  Times  and  Gazette,"  1865. 


42 


THE    CAVITIES    OF    THE    UTERUS. 


pearance  is  commonly  due  to  senile  atrophy.  The  apex  is  pierced  by 
an  opening  which  leads  to  the  cavity  of  the  uterus.  This  opening,  the 
OS  externum  or  os  tincce,  looks  a  little  backwards.  In  the  virgin  it  is  a 
transverse  fissure,  bordered  by  two  lips,  one  anterior,  the  other  pos- 
terior, both  smooth,  the  anterior  being  thicker  and  more  prominent 
than  the  posterior  (see  Fig.  12).     To  the  touch,  says  Cruveilhier,  the 


Fig.  12. 


Fm.  13. 


Virgin  os  uteri  and  vaginal  portion  of  the 
cervix — (after  A.  Farre). 


The  u^  uteii  in  old 


OS  tincse  gives  the  same  sensation  as  the  lobule  of  the  nose.  At  the 
menstrual  epoch  the  neck  is  a  little  gaping.  In  women  who  have  had 
children  the  os  externum  uteri  represents  a  larger  fissure,  often  large 
enough  to  admit  easily  the  end  of  the  index  finger ;  the  lips  are  thicker, 
uneven,  and  often  present  notches,  the  remains  of  the  rents  they  have 
undergone  during  labor.  One  of  these  notches  is  almost  always  seen 
towards  the  left  commissure,  which  is  explained  by  the  frequency  of 
the  left  occipito-anterior  position. 

Sometimes  the  portion  of  the  uterus  which  projects  into  the  vagina 
quite  disappears.  The  vagina  then  terminates  in  a  cul-de-sac,  at  the 
bottom  of  which  is  felt  only  a  contraction  separating  the  cavity  of  the 


Fig.  14. 


The  uterus  in  old  age,  showing  a  return  to  the  infantine  proportions  between  the  body  and  cervix 
(after  A.  Farre),  half  natural  size ;  o,  o,  the  shrivelled  ovaries. 


vagina  from  that  of  the  uterus.     This  condition  is  most  frequent  in 
old  age. 

The  Cavity  of  the  Uterus. — The  uterus  is  hollowed  by  a  cavity  very 
small  in  proportion  to  the  volume  of  the  organ.  Excepting  during 
pregnancy,  and  certain  morbid  states,  the  walls  of  this  cavity  are  always 


THE    CAVITIES    OF    THE    UTERUS. 


43 


ill  contact.  It  represents  an  irregular  canal,  divided  by  a  sort  of  hour- 
glass constriction  in  the  middle  into  two  parts  :  the  one  upper,  flattened 
out  transversely,  is  the  cavity  of  the  body  of  the  uterus ;  the  other,  in- 
ferior, fusiform,  is  the  cavity  of  the  neck  of  the  uterus.  The  constricted 
part  which  separates  the  two  cavities  is  the  os  uteri  internum,  or  isthmus 
of  the  uterus  (see  Fig.  10). 

The  cavity  of  the  body  is  triangular,  and  has  an  orifice  at  each 
angle :  one  inferior,  which  communicates  with  the  cavity  of  the  cervix, 
and  one  at  each  upper  angle,  which  lead  to  the  Fallopian  tubes.  The 
uterine  orifices  of  the  tubes  are  situated  at  the  bottom  of  the  funnel- 


FiG.  16. 


Half  natural  size.  Shining  of  the  walls 
in  old  age,  and  return  to  the  triangular 
form  of  the  infantine  and  undeveloped 
uterus — (after  A.  Farre). 


Natural  size  of  cervix  laid  open — (after 
Hassall  and  Tyler  Smith). 


shaped  cavities,  which  are  vestiges  of  the  jjrimitive  division  of  the 
body  of  the  uterus  into  two  halves  or  horns.  This  bifidity,  normal  in 
the  lower  animals,  is  sometimes  observed  in  the  human  species.  The 
three  borders  of  the  uterine  cavity  are  convex  inwards.  In  the  mul- 
tiparous  uterus  the  cavity  of  the  body  is  more  developed,  its  borders  are 
less  convex  or  nearly  straight,  the  upper  angles  are  enlarged,  and  the 
cavity  of  the  neck  has  lost  in  length.  The  cavity  of  the  neck  of  the 
uterus  is  cylindroid  ;  flattened  from  before  backwards,  slightly  enlarged 
at  the  middle,  it  presents  on  either  wall  rugee,  or  elevations,  forming  a 
tolerably  regular  series,  known  as  the  lyra  or  arbor  vitce  (see  Fig.  16). 
On  each  of  these  walls  is  disting-uished  a  vertical  column  runnino;  along; 
the  entire  length  of  the  neck,  swelling  out  above  and  continuous  with 
the  median  column  of  the  body  of  the  uterus.  The  two  columns  of  the 
neck  do  not  descend  quite  so  low  as  the  os  externum,  but  stop  a  little 
above  the  circle  of  the  orifice,  which  is  always  smooth  (see  Fig.  16). 
M.  Guyon  has  observed  that  these  columns  are  never  situated  exactly 
on  the  median  line;  the  anterior  one  is  a  little  on  the  right,  the  pos- 
terior one  a  little  on  the  left ;  so  there  results  a  kind  of  dovetailing  of 
the  walls  of  the  neck,  especially  marked  at  the  upper  part  of  the  cavity. 
From  the  two  borders  of  each  column  a  certain  number  of  smaller  folds 
proceed,  at  more  or  less  acute  angles,  and  are  directed  upwards  and 
outwards,  resembling  a  fern  leaf.  These  oblique  folds  have  their  free 
border  directed  downwards  and  inclose  furrows  or  pits,  in  which  are 


44  DIMENSIONS    OF    THE    UTERUS. 

seen  the  gaping  orifices  of  the  uterine  glandules.  Sometimes  they 
bifurcate.  The  arbor  vitse  is  commonly  much  smoothed  down  after 
the  first  labor.  But  this  is  not  constant,  since  the  arbor  vitse  is  some- 
times found  intact  after  several  labors. 

The  isthmus  is  generally  0.20  in.  to  0.25  in.  long;  0.16  in.  across,  and 
0.12  in.  from  before  backwards  in  imparous  women.  In  multiparse 
the  length  of  the  isthmus,  which  is  always  included  in  the  measurement 
of  the  body,  is  reduced  to  0.16  in.  and  even  less.  A  female  catheter  is 
commonly  arrested  by  the  constriction  of  the  isthmus,  and  only  pene- 
trates it  under  a  certain  pressure.  After  the  cessation  of  menstruation 
the  isthmus  contracts  considerably,  and  often  is  completely  obliterated. 
The  orifice  of  the  os  externum  also  I  have  frequently  found  obliterated 
in  old  women.  M.  Guy  on  says  this  obliteration  always  coincides  with 
the  obliteration  of  the  isthmus.  This,  however,  I  have  found  to  be  far 
from  constant. 

The  inner  surface  of  the  body  of  the  uterus  is  much  more  vascular 
than  that  of  the  neck.  This  diiference  is  especially  marked  in  women 
who  have  died  during  menstruation.  The  lualls  of  the  uterine  cavity, 
apart  from  pregnancy,  are  0.40  in.  to  0.60  in.  thick.  The  thickness  is 
greater  in  women  who  have  had  children  than  in  the  virgin.  The 
thinnest  part  corresponds  with  the  insertion  of  the  tubes.  The  walls 
of  the  neck  are  thinner  than  those  of  the  body. 

The  dimensions  of  the  uterus  have  been  determined  by  M.  Richet  in 
the  following  manner :  The  uterus  remaining  intact  he  first  measured 
the  cavity  by  the  sound,  then  having  removed  the  uterus  from  the 
pelvis,  he  split  it  from  before  backwards  along  the  median  line,  and 
measured  it  again  from  the  neck  to  the  fundus  of  the  uterine  cavity 
first,  and  then  from  the  neck  to  the  upper  border  of  the  organ.  He 
obtained  the  following  dimensions  : 

The  vertical  diameter  of  the  uterus,  . 
Vertical  diameter  of  the  cavity, 
Transverse  diameter  of  the  uterus,  . 
Transverse  diameter  of  the  cavity,  . 

M.  Guyon,^  as  well  as  Richet,  has  examined  the  uterus  at  the  different 
physiological  epochs,  and  both  find  that  the  uterus  attains  its  maximum 
during  the  menstrual  periods,  and  its  minimum  in  the  intervals.  It  is 
important  in  practice  to  bear  in  mind  that  during  the  five  or  six  days 
which  precede  and  follow  the  catamenia,  the  uterine  diameters  will 
generally  exceed  the  means,  whilst  during  the  intermediate  period  they 
will  fall  a  little  below. 

The  vertical  diameter  of  the  uterus  is  divided  unequally  between 
the  body  and  the  neck.  In  the  virgin  the  longest  portion  belongs  to 
the  neck.  In  multiparous  women,  the  two  diameters  are  nearly  equal, 
the  difference,  if  any,  inclining  in  favor  of  the  body.  In  multiparse 
the  body  continues  to  grow,  whilst  the  neck  has  undergone  an  absolute 
or  comparative  shortening,  which  reduces  its  vertical  diameter  in  some 
cases  below  that  of  the  body. 

1  Etudes  sur  les  cavites  de  1 'uterus,  thbses  inaug.,  1858. 


the  virgin. 

In  women. 

In  mothers. 

2  20  in. 

2  52  in. 

2.72  in. 

1.80  in. 

2.20  in. 

2.44  in. 

1.24  in. 

1.80  in. 

1.90  in. 

0.60  in. 

1  08  in. 

1.24  in. 

THE    CAVITIES     OF     THE     UTERUS.  45 


CHAPTER  III. 

THE  SHAPE  OF  THE  CAVITIES  OF  THE  UTERUS. 

The  shape  of  the  cavities  of  the  body  of  the  uterus  and  of  its  cervix, 
and  the  relations  of  their  walls,  are  best  demonstrated  by  longitudinal 
sections,  and  by  transverse  sections  made  at  different  points. 

If  we  first  make  a  vertical  section  in  the  antero-posterior  direction, 
as  in  Figs.  8,  11,  we  see  that  the  walls  of  the  body  of  the  uterus  lie  in 
contact.  The  cavity  is  represented  by  a  line  running  from  the  fundus 
to  the  cervix.  This  cavity  is,  under  ordinary  circumstances,  potential 
rather  than  actual.  But  when  fluids  are  retained,  or  a  solid  body  is 
introduced  into  or  grows  in  the  space  between  the  two  walls,  the  cavity 
is  capable  of  enlarging  to  an  almost  indefinite  extent.  This  enlarge- 
ment of  the  cavity  is  always,  at  least  when  considerable,  effected  chiefly 
by  gradual  growth  of  the  uterine  walls.  When  the  uterus  is  emptied 
this  growth  ceases,  a  process  of  absorption  and  involution  takes  place ; 
and  generally  the  triangular  form  of  the  cavity  is  resumed,  the  anterior 
wall  being  again  flattened  upon  the  posterior.  Where  any  distinct 
hollow  remains,  it  may  be  assumed  that  there  is  more  or  less  habitual 
retention  of  fluids,  and  that  there  is  some  pathological  condition  of  the 
mucous  membrane,  or  obstruction  at  a  lower  point  of  the  canal. 

This  contact  of  the  walls  of  the  body  of  the  uterus,  together  with 
the  mucous  plug  usually  filling  the  cervix,  and  the  closing  of  the  vagina 
by  approximation  of  its  walls,  prevent  the  intrusion  of  air  into  the 
cavity,  and  thus  obviate  the  foulness  that  would  otherwise  result  from 
decomposition  of  the  secretions. 

The  cervical  cavity  is  fusiform  in  some  cases,  conical  in  others,  ac- 
cording to  the  extent  of  the  opening  of  the  os  externum.     Although 

Fin.  17. 


Ad  uat. — (after  A.  Farre.) 
Section  made  through  cavity  of  the  body  of  the  uterus  above  the  entrance  of  the  Fallopian  tubes. 

the  columns  of  the  arbor  vitce  are  so  adapted  as  to  dovetail  with  each 
other,  there  is  usually  a  distinct  cervical  cavity,  the  walls  not  being 
commonly  in  close  apposition. 

If  we  next  make  a  longitudinal  section  transversely,  so  as  to  separate 


46 


THE    CAVITIES    OF    THE    UTEHUS. 


along  the  entire  length  the  anterior  half  of  the  uterus  from  the  posterior, 
we  see  the  triangular  shape  of  the  cavity  of  the  body  of  the  uterus, 
with  its  two  superior  angles  drawn  out  funnel-wise,  to  be  continuous 
with  the  Fallopian  tubes,  and  its  inferior  angle  contracting  to  be  con- 


(After  A.  Farre.) 
Section  through  centre  of  cavity. 


Fig.    19. 


(After  A.  Farre.) 
Through  centre  of  cervical  canal. 


tinuous  at  the  isthmus  with  the  canal  of  the  cervix.  Below  the  isthmus 
is  the  cervical  cavity,  fusiform  or  conical.  In  multiparse,  in  whom  the 
OS  externum  is  a  wide  fissure,  the  conical  form  is  more  manifest  in  this 
section  than  in  the  antero-posterior  section,  from  its  giving  the  whole 
width  of  the  os  tincse :  but  even  in  these  the  base  of  the  cone  at  the  os 
tincse  is  commonly  more  contracted  than  the  middle  part  of  the  canal. 
In  nulliparse  the  os  externum  is  still  more  contracted,  so  that  the 
canal  approaches  the  fusiform  character.     In  many  cases   of  sterility. 


CASTS  OF  CAVITIES  OF  UTERUS.     (AFTER  GUYON.) 
Fig.  20.  Fig.  21. 


1.  Uterus  of  virgin,  ret.  17. 


2.  Multiparous  uterus,  set.  25 — 30. 
a.  Narrowing  and  lengthening  of  isthmus. 
6.  Dilatation  of  cavity  of  neck. 
c.  Narrowing  of  os  externum. 


the  OS  externum  is  a  mere  round  hole  no  bigger  than  the  os  internum, 
and  the  central  part  of  the  canal  is  then  generally  more  dilated  than 
usual,  so  that  it  is  completely  fusiform. 


THE    CAVITIES     OF    THE    UTERUS. 


47 


A  series  of  horizontal  sections,  made  through  the  walls  of  the  body, 
will  exhibit  a  narrow  line  marking  the  contact  of  the  anterior  wall 
flattened  upon  the  posterior ;  made  through  the  isthmus  or  os  uteri 
internum,  a  round  hole  of  about  the  calibre  of  a  No.  8  or  9  catheter, 
the  fibres  of  the  wall  disposed  in  a  circular  or  sphincteric  manner 
around  it ;  and  at  the  margins,  right  and  left,  the  gaping  orifices  of  the 
vessels  which  enter  the  uterus  in  greatest  size  and  number  at  this  level; 
made  lower  down  across  the  cervical  canal,  the  cavity  of  this  canal  is 
seen  somewhat  flattened  antero-posteriorly.     (See  Fig.  19.) 


CASTS  OF  CAVITIES  OF  UTERUS.    (AFTER  GUYON.) 
Fig.  22.  Fig.  23. 


3.  Multiparous  uterus,  set.  42. 
a.  Dilated  isthmus. 
6.  Marked  narrowing  of  os  externum. 


4.  Multiparous  uterus,  set.  35. 
a.  Dilatation  of  cavity  of  body. 
6.  Narrowing  and  torsion  of  isthmus. 


There  is  another  way  of  representing  the  shape  and  size  of  the  uter- 
ine cavities,  namely,  by  taking  casts  or  moulds  with  wax  or  plaster  of 
Paris.  The  information  thus  acquired  has  a  certain  value,  but  it  is 
apt  to  mislead.  Liquid  poured  into  the  uterus  distends  the  cavity,  and 
when  it  has  set  we  get  a  mould  of  a  cavity  such  as  does  not  normally 
exist.  But  in  the  case  of  morbidly  dilated  cavities,  these  casts  give 
more  accurate  representations. 


48  THE    TISSUE    OF    THE    UTERUS. 


CHAPTER  IV. 

STEUCTUKE  OF  THE  UTEEUS. 

The  structure  of  the  uterus  must  be  examined  under  the  opposite 
conditions  of  vacuity  and  of  fulness. 

A  serous  investment  pertaining  to  the  peritoneum,  a  proper  tissue 
of  muscular  nature,  an  internal  or  mucous  membrane,  vessels  and 
nerves,  are  the  constituent  parts  of  the  uterus. 

A.  The  External  or  Pe7'itoneal  Memb^xine. — The  peritoneum,  which 
has  invested  the  posterior  face  of  the  bladder,  is  reflected  over  the  an- 
terior surface  of  the  uterus,  covering,  however,  the  upper  three-fourths 
only,  the  lower  fourth  being  in  immediate  relation  with  the  bladder. 

It  passes  over  the  fundus  of  the  uterus,  clothes  the  posterior  surface 
throughout,  and  is  prolonged  for  a  short  distance  down  the  vagina,  be- 
low the  utero-sacral  ligaments,  and  then  is  reflected  upwards  over  the 
rectum.  It  is  the  transverse  extension  of  the  peritoneum  which  con- 
stitutes the  hroacl  ligament.  In  the  space  which  separates  the  bladder 
from  the  uterus,  this  membrane  forms  two  very  small  falciform  folds, 
which  bear  the  name  of  vesico-uterine  ligaments.  Two  other  folds, 
much  larger,  stretching  from  the  posterior  aspect  of  the  neck  of  the 
uterus  to  the  sides  of  the  sacrum,  constitute  the  utero-rectal,  or  utero- 
sacral  ligaments. 

The  adhesion  of  the  peritoneum  to  the  uterus,  on  a  level  with  the  neck 
and  towards  the  borders,  is  very  loose,  but  becomes  closer  the  more  we 
approach  the  median  line.  It  is  also  more  intimate  on  the  posterior 
than  on  the  anterior  aspect.  The  looseness  of  the  connection  of  the 
peritoneum  at  the  level  of  the  neck  and  borders  of  the  uterus,  explains 
the  reason  why  the  peritoneum  so  rarely  shares  in  even  considerable 
rents  of  the  cervix  uteri,  and  why  the  effusion  of  blood  in  such  cases 
takes  place  between  the  tissue  of  the  uterus  and  the  peritoneum.  It 
has  been  held  that  the  uterus  growing  during  pregnancy  appropriates  to 
itself  the  peritoneal  folds  of  the  broad  ligaments,  which  open  out  to 
permit  of  the  development  of  the  organ. 

B.  The  Proper  Tissue. — In  the  non-pregnant  state,  this  tissue  is  gray- 
ish, very  dense,  very  resisting,  and  creaks  like  fibrous  tissue  under  the 
scalpel.  If  the  consistency  of  the  body  of  the  uterus  seems  less  than 
that  of  the  neck,  this  is  solely  because  the  first  is  the  more  frequently 
the  seat  of  sanguineous  congestion.  The  proper  tissue  which  consti- 
tutes the  principal  portion  of  the  uterine  wall  is  composed  of  fibres, 
that  is,  of  parts  disposed  in  a  linear  direction.  These  fibres  belong  to 
the  muscular  tissue  of  organic  life.  The  contrary  opinion  was  long 
held.  But  comparative  anatomy,  the  microscope,  examinations  during 
gestation,  and  physiological  observations,  have  dispelled  all  doubts  upon 
this  point.     During  pregnancy,  and  in  consequence  of  the  development 


THE    MUSCULAR    WALL    OF    THE    UTERUS.  49 

of  tumors,  or  of  an  accumulation  of  liquid  in  the  uterine  cavity,  the 
proper  tissue  assumes  all  the  external  characters  and  properties  of  mus- 
cular tissue,  as  it  is  seen  in  the  instruments  of  organic  life. 

The  direction  of  the  muscular  fibres  of  the  uterus  has  been  the  sub- 
ject of  numerous  researches.  Malpighi  and  Monro  thought  there  was 
nothing  regular  in  the  disposition  of  these  fibres ;  and  in  the  empty 
state  this  appears  to  be  the  case.  They  are  so  interlaced  and  compressed, 
that  it  is  in  vain  we  seek  to  disentangle  them.  But  during  gestation, 
the  muscular  elements  having  undergone  very  considerable  develop- 
ment, the  mingling  of  the  bundles  becomes  easier  to  follow. 

It  may  be  admitted  that  the  muscular  wall  of  the  uterus  is  formed 
of  three  layers  or  planes  of  bundles — an  outer,  a  middle,  and  an  inner. 
These  three  layers  are  not  clearly  defined,  as  is  the  case  in  the  heart ; 
but  they  send  communicating  bundles  to  each  other.  The  arrangement 
of  these  muscular  bundles  is  by  no  means  constant,  but  they,  neverthe- 
less, always  approach  a  determinate  type. 

1st.  The  external  or  superficial  layer  comprises  a  longitudinal  bun- 
dle, or  rather  a  broad  median  ribbon,  and  transverse  fibres.  The  me- 
dian band,  the  looped  band  of  M.  Helie,*  arises  on  the  posterior  aspect 
of  the  uterus,  on  a  level  with  the  union  of  the  body  with  the  neck,  by 
fibres  continuous  with  the  transverse  fibres.  At  its  origin  it  is  often 
overlaid  by  a  thin  stratum  of  these  transverse  fibres.  Ascending  over 
the  posterior  surface  of  the  uterus,  it  is  reinforced  successively  by  simi- 
lar fibres,  which  are  added  to  its  bordere,  and  by  new  fibres  which  spring 
up  in  the  openings  of  its  primitive  fibres.  It  then  curves  over  the  fun- 
dus uteri,  where  its  fibres,  hitherto  parallel,  proceed  diverging,  so  that 
three  portions  may  be  distinguished — an  inner,  an  external,  and  a  mid- 
dle. The  inner  portion  often  crosses  partially  with  that  of  the  oppo- 
site side  of  the  median  line  ;  the  external  portion  runs  towards  the  an- 
gles of  the  uterus,  and  mixes  with  the  transverse  fibres.  The  fibres  of 
the  middle  portion  descend  over  the  anterior  aspect,  then  successively 
curve  outwardly,  to  be  continued  with  the  fibres  forming  the  round  lig- 
aments. Sometimes  the  innermost  fibres  of  this  bundle  reach  the  level 
of  the  isthmus  of  the  uterus,  and  in  their  turn  curve  outwardly  to  min- 
gle with  the  transverse  fibres. 

The  transverse  fibres  form  the  principal  mass  of  the  external  layer. 
On  the  lower  half  of  the  body  they  are  directly  transverse ;  at  a  higher 
level  they  converge  towards  the  angles  of  the  uterus.  Towards  the 
median  line,  the  most  superficial  fibres  sometimes  turn  up  so  as  to  be- 
come longitudinal,  and  to  be  continuous  with  the  looped  bundle.  The 
deeper  fibres  proceed  directly  from  one  side  of  the  uterus  to  the  other. 
Externally  the  superficial  fibres  are  prolonged  into  the  broad  liga- 
ments, over  the  oviducts,  and  into  the  round  and  ovarian  ligaments ; 
the  deeper  fibres  curve  round  the  borders  of  the  uterus,  passing  from 
one  aspect  to  the  other.  In  this  course  they  meet  the  arteries  and 
veins,  which  they  surround  with  contractile  rings.     At  the  same  time 

^  Kecherches  sur  la  disposition  des  fibres  musculaires  de  I'uterus  developpe  psir  la 
grossesse.     Paris,  1864. 

4 


50  THE    MUCOUS     MEMBEANE    OF    THE    UTEEUP. 

the  fibres  pass  from  one  plane  to  another,  so  that  those  which  were  at 
first  superficial,  become  deeper  as  they  get  behind. 

The  j^ire.s  of  the  neck  are  generally  transverse,  but  are  a  little  oblique 
downwards  and  inwards,  and  often  crossed  on  the  median  line.  They 
send  expansions  outwardly  into  the  broad  ligament,  backwards  into 
the  utero-sacral  ligaments,  and  sometimes  forwards  into  the  utero-vesi- 
cal  ligaments. 

2d.  The  middle  layer  of  the  muscular  fibres  of  the  uterus  forms 
about  one-third  of  the  uterine  wall.  When  sections  of  this  wall  are 
made,  it  is  distinguished  by  the  great  size  of  the  vessels,  principally 
veins,  which  traverse  it.  It  is  composed  of  muscular  bundles,  which 
cross  each  other  in  all  directions,  and  send  off  frequent  branches,  which 
circumscribe  more  or  less  completely  large  holes  or  canals  in  which  the 
bloodvessels  are  contained.  This  texture  is  the  same  throughout  the 
whole  body  of  the  uterus,  but  is  especially  manifest  in  the  region  which 
corresponds  to  the  insertion  of  the  placenta.  There  is  nothing  like  it 
in  the  neck. 

3d.  The  internal  layer  is  principally  composed  of  annular  fibres  from 
the  isthmus  as  far  as  the  orifices  of  the  Fallopian  tubes. 

But  these  fibres  are  covered  on  each  of  the  surfaces  of  the  uterus  by 
a  broad  and  thick  band  of  longitudinal  fibres,  forming  a  triangular 
bundle,  whose  base  is  superior,  and  stretches  from  one  tubal  orifice  to 
the  other;  and  whose  apex,  directed  downwards,  descends  nearly  to  the 
OS  internum  uteri.  It  is  formed  of  transverse  fibres,  which  curve  from 
below  upwards,  run  for  a  certain  distance  in  the  longitudinal  direction, 
and  then  again  become  transverse.  An  annular  bundle,  very  power- 
ful, and  always  a  little  prominent,  surrounds  the  os  internum  uteri, 
forming  a  true  sphincter,  which  explains  the  habitual  constriction  of 
this  orifice.  Muscular  rings,  whose  diameter  goes  on  diminishing  from 
within  outwards,  surround  the  infundibula  of  the  uterine  cavity.  On 
the  median  line  of  the  anterior  wall,  and  on  the  median  line  of  the 
posterior  wall,  the  rings  of  the  right  and  left  sides  meet,  and  even 
interlace.  Their  upper  halves  constitute  antero-posterior  arcs,  which 
form  the  roof  of  the  uterine  cavity.  By  their  inferior  halves  they 
begin  the  series  of  the  transverse  annular  fibres. 

In  the  neck,  on  the  middle  of  each  wall,  a  branched  muscular  bundle 
gives  rise  to  the  projections  of  the  arbor  vitfe  ;  it  rises  from  the  middle 
of  each  wall,  and  forms  arches  right  and  left.  Beneath  this  bundle, 
but  rather  deeply,  the  fibres  are  transverse  or  annular,  and  are  con- 
founded Avith  those  of  the  external  layer. 

C.  The  Internal  or  Mucous  Membrane. — Some  anatomists,  and  in  par- 
ticular Morgagni  and  Chaussier,  who  observed  the  inner  surface  after 
delivery,  have  denied  the  existence  of  the  uterine  mucous  membrane. 
But  the  microscope  has  set  at  rest  all  disputes  upon  this  point.  The 
mucous  membrane,  however,  presents  different  characters  in  the  cavity 
of  the  body  and  in  that  of  the  neck. 

1.  The  mucous  membrane  in  the  body  of  the  uterus  is  of  a  grayish  or 
rosy  white ;  its  surface  is  smooth  and  finely  punctuated.  Its  thickness, 
in  the  intermenstrual  period,  in  general  does  not  exceed  0.04  in.,  and 
in  certain  points  is  only  0.02  in.;  during  the  menstrual  jJeriods  it  swells 
considerably,  and  may  even  exceed  0.12  in. 


THE    MUCOUS    MEMBRANE    OP    THE    UTERUS.  51 

Differing  from  what  is  usually  seen  in  mucous  membranes,  the  uter- 
ine membrane  is  not  separated  from  the  muscular  tunic  by  a  distinct 
layer  of  connective  tissue  allowing  it  to  slide  on  this  tunic,  or  at  least 
marking  the  exact  limits  between  the  two  tunics.  These  limits  can, 
indeed,  scarcely  be  properly  distinguished  by  the  microscope  ;  for  a  cer- 
tain number  of  muscular  bundles  are  seen  to  penetrate  into  the  thick- 
ness of  the  mucous  membrane  between  the  uterine  glands. 

Two  distinct  layers  compose  the  uterine  mucous  membrane ;  an  epi- 
thelial layer  and  a  basement  layer.  The  latter  incloses  in  its  substance 
glands,  vessels,  and  nerves. 

The  epithelium  is  composed  of  a  simple  layer  of  cylindrical  cells, 
furnished  on  their  free  surface  with  extremely  fine  cilia,  which  sweep 
from  without  inwards.  The  vibratile  epithelium  is  continued  as  far 
as  the  middle  of  the  cervix ;  below  this,  it  is  replaced  by  a  pavement- 
epithelium  . 

The  basement  layer  is  composed  in  the  body  of  the  uterus  of  an  em- 
bryonic connective  tissue,  in  which  are  seen  closely  packed  nuclei  and 
fibre-cells  or  flattened  lamellse. 

The  uterine  glands  are  either  simple  or  bifurcated  utriculse,  very 
analogous  to  the  glands  of  Lieberkiihn  of  the  intestines.  Their  length 
is  determined  by  the  thickness  of  the  mucous  membrane.  Their  width 
is  from  0.02  in.  to  0.03  in.  Often  the  cul-de-sac,  or  blind  extremity, 
is  curved  like  a  crook  or  twisted  like  a  corkscrew.  They  open  sepa- 
rately or  in  groups  of  two  or  three  by  an  orifice  0.03  in.  in  diameter, 
at  the  bottom  of  little  depressions  observed  on  the  surface  of  the  mucous 
meiubrane.  AVheu  the  membrane  becomes  hypertrophied  under  the 
influence  of  menstruation,  the  glandules  assume  a  development  even 
greater  in  proportion.  They  are  formed  of  a  very  thin  amorphous 
membrane,  furnislied  interiorly  with  a  layer  of  cylindrical  epithelium, 
which  is  only  distinguished  from  that  on  the  free  surface  of  the  mucous 
membrane  by  the  absence  of  vibratile  cilia.  These  glandules  are  ex- 
tremely numerous.  Generally  they  are  separated  from  each  other  by  a 
distance  of  only  0.04  in.  to  0.08  in. 

2.  Neck  of  the  Uterus. — Here  the  mucous  membrane  is  much  thicker 
than  in  the  body ;  it  is  whiter,  denser,  and  less  friable.  It  is  0.04 
in.  thick ;  but  this  thickness  is  much  increased  at  the  level  of  the 
folds  of  the  anterior  and  posterior  walls.  The  mucous  membrane  of 
the  neck  is  furnished  in  its  lower  third  or  half  with  warty  or  fili- 
form papillae,  0.08  in.  to  0.25  in.  high,  and  which  are  very  numerous 
on  the  external  surface  of  the  os  tincse.  Formed  of  an  amorphous 
substance,  including  a  multitude  of  nuclei,  they  make  no  projection  on 
the  surface  of  the  epithelium.  They  are,  however,  well  seen  when  the 
epithelium  is  removed  by  maceration,  as  in  Fig.  24,  a  preparation 
made  by  Dr.  Hassall.  Between  these  folds  are  seen  a  multitude  of 
round  or  oval  orifices  from  0.12  in.  to  0.16  in.  wide,  arranged  in 
linear  series  and  leading  to  the  irregular  cavities  lined  with  cylindrical 
epithelium.  The  diameter  of  these  cavities,  which  occupy  the  whole 
thickness  of  the  mucous  membrane,  is  scarcely  larger  than  that  of  their 
openings.    They  represent  rudimentary  follicles ;  and  secrete  the  trans- 


52 


THE    MUCOUS    MEMBRANE    OF    THE     UTERUS. 


parent  and  viscous  mucus  which  is  usually  found  in  the  uterine  neck. 
The  mucous  membrane  of  the  neck  is  composed  of  a  mucous  chorion 


Fig.  24. 


(After  Tyler  Smith  and  Hassall.) 
Villi  of  the  os  uteri,  from  which  the  epithelium  has  been  removed. 

formed  almost  exclusively  of  connective  tissue,  and  of  an  epithelium 
formed  of  cylindrical  cells  in  the  upper  two-thirds  of  the  neck,  and  of 
pavement  cells  in  the  lower  third. 


Fig.  25. 


(After  Tyler  Smith  and  Hassall.) 
Extremities  of  villi  of  os  uteri,  covered  by  squamous  epithelium,  showing  their  central  deprossious 


VESSELS    AND    NERVES     OF    THE     UTERUS. 


53 


We  often  meet,  on  the  surface  of  the  uterine  mucous  membrane, 
with  spherical  transparent  vesicles  called  ovula  Nabothi.  These  are 
simply  muciparous  follicles  which  are  found  in  the  cavity  of  the  body 
as  well  as  in  that  of  the  neck,  but  which  especially  abound  in  the 


(After  Tyler  Smith  and  Hassall.) 
Villi  of  OS  uteri,  covered  by  pavement-epithelium  and  containing  looped  bloodvessels. 


neighborhood  of  the  os  uteri.  "When  small  they  remain  buried  in  the 
mucous  membrane.  They  only  become  visible  when  the  mucus  ac- 
cumulates in  their  cavities  through  the  obliteration  of  their  orifices. 
When  very  largely  developed  they  have  given  rise  to  the  suspicion  of 
serious  disease.  They  are  formed  of  an  investing  membrane  of  con- 
nective tissue,  and  of  cylindrical  epithelium ;  and  contain  a  transparent, 
vitreous,  or  colloid  liquid. 

Vessels  and  Nerves :  1st.  Arteries. — The  arteries  of  the  uterus  spring 
from  two  sources:  1st.  Some  arise  from  the  hypogastric,  and  take  the 
name  of  uterine  arteries.  Placed  at  first  on  the  sides  of  the  vagina, 
they  penetrate  the  broad  ligaments  in  the  neighborhood  of  the  cervix 
uteri,  ascend  along  the  borders  of  the  uterus,  and  anastomose  with  the 
utero-ovarian  arteries.  2d.  The  others,  not  less  considerable,  spring 
from  the  ovarian  arteries,  called  for  this  reason  by  Cruveilhier,  utero- 
ovarian  ;  they  reach  the  upper  angles  of  the  uterus,  then  descend  along 
the  borders  of  this  organ,  to  anastomose  with  the  uterine  arteries. 

The  branches  furnished  by  the  two  arteries  which,  on  either  side, 
run  along  the  border  of  the  uterus,  course  at  first  under  the  peritoneum, 
surrounded  by  the  muscular  bundles  Avhich  proceed  from  the  uterus ; 
then,  after  a  certain  course,  they  plunge  into  the  substance  of  the 
muscular  tissue,  where  they  ramify  and  anastomose  with  each  other, 


54  VESSELS    AXD    NERVES     OF    THE     UTERUS. 

and  with  the  branches  of  the  opposite  side.  All  these  branches,  which 
are  very  numerous,  are  remarkable  for  tlieir  corkscrew  twistings.  It 
was  thought  at  one  time  that  this  helicine  disposition  was  designed  to 
favor  the  development  of  the  pregnant  uterus  by  uncurling,  and  be- 
coming straight  as  the  uterus  grew ;  but,  the  fact  is,  that  the  arteries, 
eveu  in  advanced  pregnancy,  are  as  flexuous  as  in  the  non-pregnant 
state.  These  arteries  are  not  distributed  equally  to  all  parts  of  the 
uterus ;  the  neck  receives  but  a  small  number ;  at  the  neighborhood 
of  the  upper  angle  of  the  uterus,  on  the  other  hand,  the  utero-ovarian 
artery  supplies  suddenly  from  twelve  to  eighteen  tufts  of  arteries,  spi- 
rally curled,  which  cover  with  their  ramification  the  whole  of  this 
region.  At  the  level  of  the  furrow  which  separates  the  body  from 
the  neck,  M.  Huguier  has  described  an  arterial  circle  formed  by  the 
anastomoses  of  the  arteries  of  the  right  side  with  those  of  the  left. 
The  ultimate  ramifications  of  the  arteries  of  the  uterus  are  distributed 
in  the  mucous  membranes.  The  ramuscules  in  this  membrane  are  of 
importance  as  to  size  only  in  the  deeper  layers ;  beneath  the  epithelium 
they  form  a  capillary  network,  very  fine  and  close,  the  interspaces  of 
which  receive  the  orifices  of  the  glands.  The  coats  of  the  arteries  are, 
as  Mr.  Raiuey  pointed  out,  very  thick,  and  are  apt,  unless  care  be  ob- 
served, to  be  mistaken  for  the  proper  fibre  of  the  uterus. 

2d.  The  veins  of  the  uterus  are  remarkable  for  their  enormous 
development ;  they  are  large  canals  hollowed  out  of  the  thickness  of 
the  muscular  substance,  and  frequently  communicating  with  each  other. 
They  have  been  called  the  uterine  sinuses,  and  INI.  Rouget  has  de- 
scribed them  under  the  name  of  the  corpus  spongiosum  of  the  uterus. 
The  uterine  sinuses  occupy  all  the  body  of  the  uterus,  and  cease 
abruptly  at  the  level  of  the  os  uteri  internum.  The  neck  itself  has  a 
much  less  marked  venous  development.  Between  the  uterine  sinuses, 
we  find  in  the  wall  of  the  uterus  venous  ducts  twisted  spirally,  like 
the  arteries,  and  which  are  analogous  to  the  retce  mirahiles  of  the  gland 
and  corpus  spongiosum  of  the  male  urethra. 

On  the  lateral  borders  of  the  uterus  these  sinuses  communicate  with 
vast  venous  plexuses,  situated  in  the  thickness  of  the  broad  ligaments, 
and  continuous  below  with  the  vaginal  plexus,  and  above  with  the 
subovarian  plexus.  They  have  received  the  name  of  the  jjamjnniform 
plexuses.  From  these  plexuses  proceed  below,  the  pudic  veins ;  in  the 
middle,  the  uterine  veins ;  above,  the  ovarian  veins.  These  last  pre- 
sent but  very  few  valves,  and  assume  full  development  only  after 
puberty. 

3d.  The  lymphatic  vessels,  during  pregnancy  and  after  delivery,  are, 
like  the  veins,  of  considerable  size.  They  form  several  planes  in  the 
thickness  of  the  uterus  ;  the  superficial  are  the  largest.  They  are  di- 
vided into  two  groups ;  those  of  the  neck,  which  run  to  the  pelvic 
ganglia ;  those  of  the  body,  which  terminate  in  the  lumbar  ganglia. 
These  last  accompany  the  utero-ovarian  veins.  Dr.  Lucas-Champon- 
niere^  describes  a  ganglion  situated  above  the  lateral  vaginal  cul-de-sac, 

1  Lymphatiques  uterins  et  lymphangite  uterine.  Bull,  dc  la  Soc.  Med.  deshopi- 
taux  de  Paris.  Vol.  vii. 


THE  NERVES  OF  THE  UTERUS.  55 

closely  applied  at  the  union  of  the  body  and  neck.  When  missing, 
there  are  always  networks  of  lymphatics  closely  packed.  Gallard 
thinks  this  ganglion  or  network  plays  an  important  part  in  pathology, 
as  the  starting-point  of  puerperal  and  other  affections. 

4th.  The  nerves  proceed,  some  from  the  renal  plexuses  and  inferior 
mesenteric,  to  reach  the  uterus,  being  closely  bound  to  the  utero- 
ovarian  arteries  ;  others,  proceeding  from  the  hypogastric  plexus,  are 
formed  by  some  anterior  branches  of  the  sacral  nerves,  and  by  branches 
proceeding  from  the  lumbar  ganglia  of  the  great  sympathetic.  These 
two  plexuses  anastomose  in  the  thickness  of  the  broad  ligaments,  and 
send  oif  filaments  over  the  two  surfaces  of  the  uterus  which  penetrate 
into  the  substance  of  the  organ,  keeping  in  intimate  contact  with  the 
arteries,  or  coursing  in  the  spaces  between  the  arteries. 

The  filaments  are  found  in  greatest  number  at  the  union  of  the  neck 
and  body  of  the  uterus.  The  existence  of  nerves  in  the  uterine  neck 
was  denied  by  Jobert,  but  has  been  affirmed  by  Robert  Lee,  Lud. 
Hirschfeld,  and  Richet.  This  last  anatomist  says  he  has  several  times 
been  able  to  trace  nervous  filaments  as  far  as  the  middle  of  the  neck, 
and  everything  points  to  the  belief  that  the  labia  of  the  os  tincse  are 
not  absolutely  deprived  of  nerves,  although  it  has  not  been  possible  to 
demonstrate  them  in  this  part. 

The  question  of  the  supply  of  nerves  to  the  uterus  has  been  the  sub- 
ject of  keen  and  protracted  controversy ;  and  it  is  a  source  of  satisfac- 
tion that  numerous  appeals  to  nature  have  been  made  by  able  anato- 
mists to  determine  the  points  at  issue.  I  am  not  aware  that  any  recent 
observer,  possessing  full  means  of  investigation  and  bringing  all  the 
modern  aids  to  minute  dissection  to  the  task,  has  confirmed  the  descrip- 
tions of  Dr.  Robert  Lee.  It  would,  therefore,  only  incumber  a  didactic 
work  to  reproduce  the  unsupported  views  of  this  autlior.  The  researches 
of  Hirschfeld,  Richet,  Lobstein,  and  Boulard,  conducted  with  unques- 
tionable skill  and  candor,  all  go  to  negative  the  conclusions  of  Dr.  Lee, 
and  to  substantiate  the  accuracy  of  the  descriptions  of  Dr.  Snow  Beck. 
The  best  and  most  impartial  summary  of  this  important  matter,  and 
which  may  be  taken  to  be  the  latest  and  most  authentic  expression  of 
anatomical  science,  is  the  following  account  by  M.  Boulard,  adopted  by 
Cruveilhier : 

1.  The  nerves  of  the  uterus  are  very  few  in  number. 

2.  They  do  not  increase  in  size  during  pregnancy.  The  principal 
differences,  observed  during  pregnancy  and  in  the  non-pregnant  state, 
bear  more  upon  the  state  of  the  plexuses  than  on  the  volume  of  the 
nerves. 

3.  In  the  child,  the  elements  of  these  plexuses,  crowded  together, 
seem  to  constitute  a  true  nervous  membrane ;  from  these  there  proceed 
very  delicate  nerves,  which  run  to  the  uterus  and  broad  ligaments  to 
give  off  their  filaments,  which  are  entirely  capillary. 

4.  In  woman  whose  uterus  is  developed,  the  plexus,  as  Beck  observed, 
is  carried  higher  up ;  its  elements  are  separated,  and  form  more  or  less 
considerable  spaces  ;  and  as  to  the  nerves  issuing  from  it,  they  only  dif- 
fer in  being  longer,  coinciding  with  greater  tenuity  if  compared  with 
those  met  with  in  the  normal  uterus  of  an  adult  woman. 


56  THE    VAGIXA. 

5.  These  nerves  issue  from  the  hypogastric  ganglion,  as  well  as  from 
the  nervous  ring  or  ganglion  which  surrounds  the  urethra  at  its  entry 
into  the  bladder.  They  reach  the  sides  of  the  uterus,  and  thence  fol- 
low in  part  the  distribution  of  the  arteries.  In  every  case  they  are  con- 
stantly accompanied  by  a  very  fine  arteriole.  Some,  very  fine,  reach  the 
anterior  and  posterior  surfaces,  as  well  as  the  fundus  of  the  uterus. 

6.  As  to  the  neck,  imitating  the  prudent  reserve  of  Longet,  Boulard 
does  not  absolutely  decide  the  question,  on  account  of  the  extreme  dif- 
ficulty of  the  dissection.  He,  however,  believes  that  the  uterine  neck, 
that  is  the  vaginal  portion,  is  not  completely  deprived  of  nerves.  He 
thinks  he  has  traced  a  nervous  filament  ramifying  in  the  anterior  lip  of 
the  OS  tinc£8. 

7.  ]M.  Boulard  has  never  seen  uterine  plexuses  or  ganglia.  It  is 
enough,  he  says,  to  cast  the  eye  upon  the  walls  of  a  developed  iiterus,  after 
having  removed  the  peritoneum,  to  recognize  how  easy  it  is  to  fall  into 
error,  and  how  easy  to  represent  as  nerves  and  ganglia,  muscular  fibres, 
venulse,  lymphatic  vessels,  &c.,  especially  after  a  prolonged  submer- 
sion. 

On  the  other  hand,  Frank enhaiiser,^  whilst  to  a  great  extent  coin- 
ciding with  those  who  doubt  the  real  nervous  character  of  the  structures 
described  as  such  by  Lee,  says  Snow  Beck's  plates  and  descriptions  con- 
tain many  errors.  This  he  attributes  to  Beck's  not  having  dissected 
the  parts  in  situ,  but  removed  from  the  body.  He  points  out  that  in 
Beck's  plates  of  the  gravid  uterus,  the  nervous  filaments  are  remark- 
ably few  and  small,  and  suggests  that  the  specimens  must  have  been 
extraordinarily  scantily  supplied,  or  what  is  more  likely,  were  cut 
away.  Frankenhaiiser  says  the  plates  of  Walter^  are  the  best  yet  pub- 
lished, being  far  more  accurate  than  the  oft-repeated  ones  of  Tiedemann. 
Walter  was  the  first  to  demonstrate  a  lateral  ganglion  on  the  uterine 
neck. 


CHAPTER  V. 

THE    VAGINA. 


The  vagina  is  a  membranous  canal  extending  from  the  vulva  to  the 
uterus.  It  is  at  the  same  time  the  organ  of  cojnilation  in  women,  and 
the  canal  serving  for  the  passage  of  the  menstrual  blood  on  the  one 
hand,  and  of  the  product  of  conception  on  the  other. 

It  is  situated  in  the  cavity  of  the  pelvis,  between  the  bladder  and 

1  Die  Nerven  der  Gebiirmutter.     Jena,  1867. 

2  Tabulse  nervorum  thoracis  et  abdominis.     Bcrolini,  1783. 


THE    VAGINA.  57 

the  rectum.  Maintained  in  its  position  by  intimate  adhesions  with  the 
surrounding  parts,  the  vagina  is  still  not  so  fixed  but  that  it  may  un- 
dergo an  inversion  upon  itself  like  the  finger  of  a  glove  or  an  invagina- 
tion. This,  in  fact,  is  the  true  nature  of  most  of  the  cases  of  so-called 
prolapsus  with  procidentia  of  the  uterus.  It  is  to  be  observed  that  the 
anterior  wall  of  the  vagina  is  shorter  than  the  posterior  wall ;  the  dif- 
ference being  from  0.4  in.  to  0.8  in. 

The  vagina  is  not  of  equal  width  in  all  parts  of  its  length.  Its 
lower  or  vulvar  orifice  is  the  narrowest  part :  its  upper  extremity  has 
much  larger  dimensions.  In  women  who  have  had  children,  the 
fundus  of  the  vagina  forms  a  large  bag,  in  which  the  speculum  may  be 
made  to  sweep  freely,  and  in  which  also  a  large  quantity  of  blood  may 
accumulate  in  cases  of  uterine  hemorrhage.  Moreover,  this  canal  is 
eminently  dilatable,  as  is  proved  by  parturition :  it  is  at  the  same  time 
elastic ;  and  after  labor  it  returns  nearly  to  its  original  dimensions. 
The  part  which  is  most  dilatable  and  the  least  elastic  is  certainly  the 
upper  part,  to  which  the  name  of  vaginal  bag  might  well  be  given, 
whilst  the  lower  orifice  might  be  called  the  vaginal  strait. 

When  not  dilated  by  a  foreign  body,  the  walls  of  the  vagina  touch 
each  other  at  every  part,  so  that  its  cavity  is  completely  closed.  This 
may  be  clearly  demonstrated  by  watching  the  behavior  of  the  vagina 
during  the  withdrawal  of  the  tubular  or  bivalve  speculum.  As  the 
instrument  retreats  from  the  fundus,  the  walls  of  the  vagina  close  up 
behind  it,  and  even  help  to  expel  the  speculum  by  its  elasticity  and 
contractile  action.  There  are,  however,  cases  in  which  the  fundus  of 
the  vagina  presents  a  true  cavity,  the  walls  not  being  in  contact.  This 
I  have  chiefly  seen  in  women  who  were  subject  to  prolapsus.  If  a 
horizontal  section  of  the  organ  is  made,  it  exhibits  a  transverse  slit  not 
always  of  exactly  similar  shape.  Generally  this  slit  is  slightly  curvi- 
linear, with  anterior  convexity,  and  each  of  the  two  extremities  falls 
upon  an  antero-posterior  slit,  which  gives  to  the  whole  the  form  of  the 
letter  H.  This  form  is  perfectly  adapted  to  that  of  the  neighboring 
parts;  for  the  urethra  is  placed  in  the  opening  of  the  anterior  bi'anches, 
and  the  rectum  is  received  into  the  posterior  space.  The  transverse 
branch  is  generally  about  0.25  inch  long  in  the  adult.  In  the  child 
it  is  shorter,  and  the  section  takes  rather  the  shape  of  a  star. 

Relations. — 1.  The  anterior  aspect  of  the  vagina,  which  presents  a 
slight  concavity  in  the  transverse  direction,  answers  above  to  the  base 
of  the  bladder.  To  this  oro;an  the  vagina  is  united  bv  a  dense  fila- 
mentous  cellular  tissue.  Lower  down  the  vagina  is  united  to  the 
urethra,  and  the  relation  is  so  intimate  that  the  urethra  seems  to  be 
hollowed  out  of  the  anterior  wall  of  the  vagina.  The  urethra  may  thus 
be  felt  like  a  prominent  cord  running  along  the  median  line.  It  thus 
forms  an  excellent  guide  to  the  situation  of  the  meatus,  serving  as  a 
direct  clue  in  passing  the  catheter.  This  intimate  adhesion  of  the 
vagina  with  the  bladder  and  urethra  explains  why  these  latter  organs 
are  constantly  dragged  down  in  displacements  of  the  uterus. 

2.  The  idosterior  aspect  of  the  vagina  answers  to  the  rectum,  through 
the  peritoneum  in  its  upper  third  quarter,  and  immediately  in  its  two 
lower  thirds  or  three  quarters.     Hence  it  is  seen  that  when  the  pos- 


58  THE    VAGINA. 

terior  wall  of  the  vagina  is  torn  in  its  upper  third  or  fourth,  the  intes- 
tines may  fall  through  the  rent.  The  vagina  adheres  to  the  rectum  by 
a  cellular  tissue  much  looser  than  that  between  the  bladder  and  vagina, 
so  that  the  rectum  is  not  so  liable  to  be  dragged  down  in  the  displace- 
ment of  the  vagina. 

The  recto-vaginal  septum  is  the  septum  formed  by  the  apposition  of 
the  posterior  wall  of  the  vagina  and  of  the  anterior  wall  of  the  rectum. 
Inferiorly  the  rectum  detaching  itself  from  the  vagina,  there  is  formed 
a  triangular  space,  whose  base  is  below,  and  whose  antero-posterior 
diameter  defines  the  thickness  of  the  perineum. 

3.  The  lateral  borders  of  the  vagina  give  attachment  above  to  the 
broad  ligaments;  below  to  the  pelvic  aponeurosis.  They  are  crossed 
by  the  levatores  ani  muscles,  which,  however,  take  no  insertion  here, 
and  answer  to  the  adipose  tissue  of  the  perineum  and  to  the  venous 
plexuses. 

The  inner  surface,  or  mucous  membrane  of  the  vagina  is  smooth  in 
its  upper  portion,  and  presents  on  its  two  walls  flattened  rounded 
tubercles,  measuring  from  0.04  in.  to  0.12  in.  in  diameter,  and  pressed 
against  each  other;  or  else  there  are  crests  or  transverse  imbricated 
prominences  representing  very  nearly  the  irregular  asperities  of  the 
roof  of  the  palate.  These  different  prominences  all  spring  from  a 
median  crest,  which  stretches  under  the  form  of  a  raphe  along  the  walls 
of  the  vagina.  The  two  median  raphes  are  called  the  columns  of  the 
vagina.  They  present  wide  dissimilarities  in  individuals  in  form  and 
size,  and  appear  to  be  a  vestige  of  the  vice  of  conformation  which  con- 
sists in  a  median  vaginal  septum — a  vice  which,  although  coinciding 
most  frequently  with  bifidity  of  the  uterus,  may  exist  independently. 
The  anterior  column  sometimes  begins  immediately  behind  the  meatus 
urinarius,  sometimes  at  a  little  distance  from  this  orifice  under  the  form 
of  a  large  tubercle  which  serves  as  a  guide  in  introducing  the  catheter. 
Greatly  developed  and  very  prominent  at  this  point,  it  gradually 
diminishes,  and  is  insensibly  lost  in  the  upper  third  of  the  vagina. 
The  anterior  column  is  often  divided  by  a  median  groove,  more  or  less 
deep,  into  two  lateral  portions. 

The  posterior  column  is  generally  less  prominent  than  the  anterior. 

The  columns  of  the  vagina  are  formed  of  a  kind  of  cavernous  or 
spongy  tissue.  The  venous  plexuses  situated  around  the  vagina  send 
numerous  prolongations  into  the  thickness  of  the  muscular  tunic,  and 
even  into  the  mucous  tunic;  around  these  the  bundles  of  muscular 
fibres  interlace  in  all  directions,  representing  the  trabeculse  of  erectile 
tissues. 

The  rugse  of  the  vagina,  very  numerous  in  the  new-born  child  and 
in  virgins,  are  partly  obliterated  after  delivery  in  the  upper  part  of  the 
vagina;  but  they  always  persist  in  the  lower  part,  and  especially  at 
the  vulvar  orifice  and  in  front.  These  rugosities  are  not  folds,  and 
cannot  serve  in  facilitating  the  distension  of  the  vagina. 

The  inferior  or  vulvar  orifice  presents  in  front  an  extremely  rugous 
transverse  prominence.  This  prominence,  which  is  seen  as  soon  as  we 
separate  the  labia  majora  and  minora,  narrows,  and  even  seems  to  close 
the  entrance  of  the  vagina.     It  belongs  to  the  anterior  column. 


STRUCTURE    OF    THE    VAGINA.  59 

The  vulvar  orifice  is  not  situated  in  the  centre  of  the  inferior  strait  of 
the  pelvis ;  it  approaches  the  pubic  arch,  and  is  separated  from  the 
coccyx  by  a  much  more  considerable  space.  Even  after  labor,  and 
throughout  life,  the  vulvar  orifice  remains  narrower  than  the  rest  of 
the  vaginal  canal.  Hence,  a  well-designed  speculum  should  pass  the 
vulva  easily,  and  admit  of  expanding  at  the  fundus  of  the  vagina. 

In  virgins,  the  orifice  is  provided  with  a  membrane,  the  existence  of 
which  is  constant  in  the  normal  state,  but  whose  form  is  subject  to 
numerous  variations.  This  is  the  hymen,  from  o/iijv,  a  pellicle ;  it  is  a 
kind  of  diaphragm  interposed  between  the  internal  genital  parts  on  the 
one  side,  and  the  external  parts  and  the  orifice  of  the  urethra  on  the 
other. 

This  membrane  is  usually  crescentic  with  the  concavity  anterior ;  it 
occupies  the  posterior  half  of  the  circumference  of  the  vulvar  orifice, 
and  its  extremities  come  forward  to  lose  themselves  on  the  sides  of  the 
meatus  urinarius.  Sometimes  it  forms  two-thirds  of  a  circle,  or  even 
a  complete  circle,  perforated  near  the  anterior  part  of  its  circumference. 
The  adherent  border  of  the  hymen  is  its  thickest  portion.  Its  free 
border  is  thin,  concave,  often  irregular,  notched  in  shreds  or  fringes, 
which  lap  over  the  meatus.  Not  seldom  the  hymen  forms  a  membrane 
which  completely  closes  the  inferior  orifice  of  the  vagina,  constituting 
the  vice  of  conformation  known  as  imperforate  vagina.  The  hymen  is 
usually  thin  and  fragile,  and  is  easily  ruptured  on  the  first  sexual  rela- 
tions. But  it  may  be  very  resisting,  fibrous,  or  even  cartilaginous,  and 
rendering  copulation  impossible.  It  has  also  happened  that  the  hymen 
is  very  loose,  or  provided  with  a  large  opening ;  has  been  simply  pushed 
back  by  the  penis  without  being  torn,  and  has  been  preserved  intact 
until  the  moment  of  labor.  It  has  even  been  known  to  persist  in 
prostitutes.  When  the  hymen  has  been  torn,  the  bleeding  shreds  are 
retracted  and  cicatrize;  they  shrink,  and  give  rise  to  the  tubercles  called 
carimculce  myrtiformce.  The  number,  form,  and  situation  of  these 
carunculae  vary  extremely.  Most  frequently  they  are  three,  thick  and 
fleshy,  and  occupy — one,  the  posterior  part,  the  other  two  the  sides  of 
the  entrance  of  the  vagina.  Sometimes,  instead  of  tubercles,  lengthened 
shreds  are  found,  or  slight  eminences  with  hooked  border,  like  a  cock's- 
comb,  or  small  pediculated  polypi.  The  laceration  of  the  hymen  may 
be  partial ;  then  it  persists  as  a  complete  half-circle,  narrow,  with  notched 
edges,  or  with  fissures  extending  to  the  base. 

The  hymen  is  constituted  by  a  mucous  fold,  containing  between  its 
lamellae  a  layer  of  cellular  tissue,  inclosing  numerous  elastic  fibres,  and 
some  muscular  bundles  of  organic  life.  Some  bloodvessels  ramify  in 
its  thickness.     Pavement-epithelium  covers  its  two  surfaces. 

Structure  of  the  Vagina. — Thin  above,  the  vagina  thickens  considera- 
bly at  the  level  of  the  urethra,  and  terminates  by  a  rugous,  and  very 
prominent  enlargement,  forming  the  protuberance  at  the  entrance  of  the 
vagina,  already  described.  The  vagina  invested  behind,  for  a  short 
space,  by  the  peritoneum,  has  membranous  walls  not  at  all  resembling 
those  of  the  uterus.  They  are  composed  essentially  of  an  internal  or 
mucous  coat,  and  of  an  external  or  muscular  coat,  which  it  is  impossible 
to  isolate  by  the  scalpel,  but  which,  on  section,  may  be  distinguished 


60  THE    BULB    OF    THE    VAGINA. 

by  their  color.  The  first  is  white,  the  second  reddish.  Their  thickness 
increases  as  we  approach  the  vulvo-vagiual  orifice.  Around  these  two 
tunics  is  stretched  a  thin  layer  of  cellulo-fibrous  tissue,  in  which  are 
found  numerous  elastic  fibres. 

The  muscular  tunic  of  the  vagina  is  composed  of  bundles  anastomos- 
ing and  crossing  so  as  to  form  nets  in  the  large  openings  filled  up  with 
connective  tissue.  Sometimes  the  connective  tissue,  sometimes  the 
muscular  predominates. 

The  disposition  of  the  muscular  bundles  presents  nothing  regular. 
The  longitundinal  and  the  circular  fibres  do  not  form  distinct  layers. 
The  first,  however,  predominate  near  the  mucous  membrane,  the  latter 
near  the  external  surface  of  the  vagina.  According  to  M.  Rouget,  the 
longitudinal  or  oblique  fibres  cross  from  side  to  side  of  the  vagina;  one 
part  are  continuous  above  with  the  external  longitudinal  fibres  of  the 
uterus;  the  other  part,  more  numerous,  run  downwards  and  backwards 
on  the  sides  of  the  rectum,  and  pass  between  the  large  vessels,  united 
here  into  plexuses. 

The  vaginal  mucous  membrane  is  formed  of  a  very  dense  connective 
tissue,  abounding  in  elastic  fibres.  This  it  ig  which  explains  its  great 
strength  and  the  enormous  distension  it  can  undergo  in  the  act  of 
labor,  without  bursting.  Numerous  vascular  papillae,  conical  or  fili- 
form, cover  the  surface  of  the  membrane ;  but  they  are  buried  and 
hidden  in  the  investing  stratified  pavement-epithelium.  They  are 
met  with  also  in  the  interval  of  the  prominences  of  the  vaginal  mu- 
cous membrane.  They  are  absent  only  in  the  neighborhood  of  the 
uterine  neck. 

There  are  no  glandules  in  the  vaginal  mucous  membrane.  Accord- 
ing to  Henle  there  are  found  exceptionally  follicles  analogous  to  the 
solitary  follicles  of  the  intestine,  especially  in  the  upper  portion  and  on 
the  uterine  neck. 

The  Bulb  of  the  Vagina. — Besides  the  rugous  tubercle  found  in  front 
of  the  orifice  of  the  vagina  there  exists  around  this  orifice  a  swell- 
ing or  large  cavernous  body,  filling  the  space  which  separates  the  en- 
trance of  the  vagina  from  the  roots  of  the  clitoris.  This  is  the  bulb 
of  the  vagina.  Not  very  thick  in  front  where  it  is  placed  between  the 
meatus  urinarius  and  the  clitoris,  it  swells  progressively  from  this 
middle  portion,  and  ends  below  on  the  sides  of  the  vagina  by  a  rounded 
extremity.  The  posterior  part  of  the  vaginal  orifice  only  is  deprived 
of  bulb.  It  would  be  more  exact,  perhaps,  to  admit  two  bulbs,  one  on 
either  side.  These  two  bulbs  have  been  compared  by  Kobelt  to  two 
gorged  leeches.  The  dimensions  of  the  injected  bulb  according  to 
Kobelt  are:  length,  1.50  in.;  width,  0.50  in.  to  0.80  in.;  thickness, 
0.36  in.  to  0.50  in.  But  these  vary  extremely  according  to  age,  fre- 
quency of  sexual  relations,  of  labors,  and,  lastly,  to  individual  peculi- 
arities. The  external  surface  of  the  bulb  is  convex,  and  covered  by 
the  constrictor  muscle  of  the  vagina ;  it  answers  to  the  ischio-pubic 
ramus.  Its  internal  surface  is  concave,  and  is  applied  around  the 
vaginal  orifice.  The  two  halves  of  the  bulb  are  united  anteriorly, 
from  which  part  issue  numerous  veins,  establishing  a  communication 
between  the  bidb  and  the  gland  and  corpora  cavernosa  of  the  clitoris. 


INDICATIONS     FOR    EXAMINATION.  65 


CHAPTER  VI. 

CONDITIONS  INDICATING  NECESSITY  FOR  EXAMINATION DISORDER  OF 

FUNCTION DISTANT  AND  CONSTITUTIONAL  REACTIONS — THE  SUB- 
JECTIVE SIGNS  OF  LOCAL  DISEASE  INDICATE  APPEAL  TO  OB- 
JECTIVE SIGNS — COMPARISON  OF  STUDY  OF  DISEASE  OF  PELVIC 
ORGANS  TO  THAT  OF  SKIN  AND  EYE DISTURBANCE  OF  FUNC- 
TIONS OF  OVARIES,  UTERUS,  AND  VAGINA AMENORRHGEA,  REAL 

AND  OCCULT;    MENORRHAGIA;    DYSMENORRHCEA DYSPAREUNIA 

RETENTION   OF    URINE STERILITY ABORTION DISCHARGES, 

SANGUINEOUS,       MUCOUS,      PURULENT,      ALBUMINOUS,      WATERY, 

FLESHY,      MEMBRANOUS PAIN,       LUMBO-DORSAL,        INGUINAL, 

PELVIC, 

There  is  nothing  special  in  the  mode  of  studying  the  diseases  of 
women.  Just  as  the  ophthahnic  surgeon  is  led  to  examine  the  eye  be- 
cause the  patient  complains  of  loss  or  disturbance  of  its  function,  or 
because  he  feels  pain  in  it,  or  has  some  other  subjective  symptom  re- 
ferred to  that  organ,  so  by  disturbances  of  function  or  some  other  sub- 
jective sign  are  we  led  to  the  discovery  of  disease  of  the  sexual  organs. 
When  the  function  of  an  organ  is  disturbed,  the  prima  facie  inference 
is  that  the  organ  itself  which  constitutes  the  mechanism  by  which  that 
function  is  performed  is  out  of  gear.  This  is  not  indeed  always  abso- 
lutely true ;  because  an  impaired  state  of  the  blood,  or  disordered  in- 
nervation, or  derangement  of  a  different  organ,  may  entail  the  func- 
tional disorder  which  arrests  our  attention.  The  genital  organs  are  no 
exception  to  this  proposition.  The  functions  of  the  ovaries,  uterus,  or 
vagina  may  be  seriously  deranged  by  a  state  of  anaemia  or  blood  poi- 
soning, by  disease  of  the  nervous  centres,  by  disease  of  the  heart,  lungs, 
or  liver.  These  functions  may  be  even  more  seriously  affected  by  me- 
chanical pressure  in  contiguous  parts.  Still  the  fact  remains  that  we 
can  hardly  appreciate  rightly  or  successfully  treat  these  primary  or 
correlated  diseases  if  we  do  not  take  into  careful  consideration  the  state 
of  the  genital  organs  themselves.  The  general  or  distant  affections 
require  to  be  investigated  and  treated ;  but  it  is  not  sate  to  overlook 
the  organs  that  may  be  secondarily  involved. 

It  is  needless  to  say  that  every  woman  who  is  ill  and  seeks  advice 
does  not  suffer  from  disorder  of  the  sexual  system.  She  may  labor 
under  various  constitutional  disorders,  and  under  disorders  of  parts  of 
the  body  quite  independent  of  the  sexual  system.  On  the  other  hand, 
general  or  local  disorders  may  in  their  course  react  upon,  and  induce 
disorder  in,  the  sexual  system.  And  there  are  disorders  of  this  special 
system,  commencing  in  it,  aud  in  their  turn  reacting  upon,  and  induc- 
ing disorder  in,  distant  organs  or  in  the  general  system. 

These  inter-reactions  are  exceedingly  frequent.     Indeed,  it  may  be 


66  INDICATIOiSrS    FOR    EX  A  MIUT  AT  10  N. 

affirmed  that  no  severe  constitutional  disorder  can  long  continue  in  a 
woman  during  the  predominance  of  the  ovarian  function  without  en- 
tailing disturbance  in  this  function.  And  the  converse  is  also  true, 
that  disorder  of  the  sexual  organs  cannot  long  continue  without  entail- 
ing constitutional  disorder,  or  injuriously  affecting  the  condition  of 
other  organs. 

These  facts  point  to  the  necessity  of  guarding  against  the  error  of 
fixing  our  attention  too  specially  uj)on  one  particular  class  of  symp- 
toms or  upon  one  organ.  Whilst  searching  out  the  part  which  is  more 
especially  the  seat  of  diseased  action,  we  must  be  careful  not  to  over- 
look possible  disease  elsewhere,  and  not  to  neglect  to  observe  the  mu- 
tual reactions.  The  clinical  physician,  although  led  by  the  intuition  of 
experience  to  seize  quickly  upon  the  offending  j)art^  will  not  omit  to 
pass  under  review  the  state  and  working  order  of  the  other  parts.  In 
this  manner  most  important  complications  are  often  brought  most  un- 
expectedly to  light;  and  in  every  case  some  useful  indication  in  treat- 
ment is  discovered.  The  late  Professor  Chomel,  a  man  of  admirable 
skill,  sagacity,  and  judgment,  never  failed,  when  a  new  case  of  disease 
came  under  his  care,  to  interrogate  successively  every  function.  Thus, 
I  have  seen  him  in  a  case  of  pneumonia,  the  signs  of  which  at  once 
arrested  attention,  proceed  nevertheless  to  explore  the  abdomen,  the 
uterus,  and  the  rectum.  This  may  look  like  carrying  out  a  principle 
to  extremes.  Yet  who  shall  say  that  Chomel,  as  a  clinical  teacher  or 
as  a  physician,  was  wrong  ? 

It  is  not,  indeed,  necessary,  in  ordinary  practice,  to  follow  out  in 
rigorous  completeness  the  plan  which  to  the  clinical  professor  may 
seem  desirable.  It  will  therefore  be  usefal  to  ascertain  lohat  are  the 
leading  symptoms  ivhioh,  alone  or  grouped,  indicate  such  disorder  of  the 
sexual  organs  as  to  call  for  direct  exploration? 

This  is  the  question  we  have  set  before  us :  When  a  woman  presents 
herself,  complaining  of  certain  symptoms,  chiefly  subjective,  some,  or 
perhaps  none,  referred  to  the  pelvis,  how  are  we  to  act  ?  Will  these 
subjective  symptoms  enable  us  to  refer  them  to  their  cause,  to  establish 
a  diagnosis,  to  give  satisfactory  indications  for  treatment  ?  Hardly. 
We  must  therefore  call  to  our  aid  the  objective  signs  ;  we  must  weigh  and 
determine  the  significance  of  these  before  we  can  arrive  at  a  conclusion 
at  all  precise  or  trustworthy  as  to  the  underlying  pathological  condi- 
tion. The  whole  tendency  of  modern  medicine  is  to  subject  every 
organ  which  manifests  functional  disorder  to  direct  physical  explora- 
tion, in  order  that  it  may  solve  the  question  presented  obscurely  by  the 
subjective  signs.  The  sound,  the  probe,  the  stethoscope,  the  laryngo- 
scope, the  otoscope,  the  ophthalmoscope,  the  various  forms  of  specu- 
lum, are  only  so  many  contrivances  for  enabling  us  to  project  or  ex- 
tend the  senses  of  touch,  sight,  and  hearing  into  the  internal  struc- 
tures. In  the  case  of  the  skin,  all  is  at  once  exposed  to  direct  observa- 
tion ;  and,  as  Alibert  remarked,  we  should  be  glad  to  have  the  same 
advantage  in  investigating  and  treating  the  diseases  of  the  heart,  lungs, 
liver,  kidneys,  and  nervous  centres.  Why  is  it  that  the  study  of  the 
pathology  of  the  skin  and  of  the  eye  is  invested  with  such  fascinating 
interest?     Those  who  devote  themselves  with  the  greatest  zeal  and 


INDICATIONS    FOE    EXAMINATION.  67 

success  to  this  study  affirm  that  it  is  because  the  skin  and  the  eye  re- 
veal their  condition  directly  to  the  senses,  and  thus  furnish  not  only 
positive  objective  signs  which  the  patient  can  neither  suppress  nor  mis- 
represent, but  also  because  in  this  direct  observation  of  the  skin  and 
eye  they  can  read  and  follow,  as  on  a  map  or  on  a  telegraphic  dial,  the 
working  of  distant  organs  and  of  many  affections  of  the  general  sys- 
tem. Here,  then,  we  see  how  the  reputed  special  practitioner,  turning 
to  account  his  special  experience,  often  acquires  an  insight  into  general 
pathology  denied  to  those  who  neglect  the  lessons  they  might  read 
upon  the  visible  organs. 

This  advantage  we  possess  to  a  great  extent  of  perfection  in  the  case 
of  the  pelvic  organs.  It  is  by  the  proper  use  of  this  advantage  that 
so  great  a  degree  of  precision  in  knowledge,  and  of  success  in  treat- 
ment of  diseases  of  women,  has  of  late  years  been  attained. 

And  there  is  one  property  in  a  high  degree  characteristic  of  the 
instruments  employed  in  the  investigation  of  the  diseases  of  women  of 
such  singular  value  that  it  ought  to  completely  silence  the  objections 
at  one  time  so  passionately  urged  against  them.  It  is  this :  the  instru- 
ments have  a  therapeutical  as  well  as  a  diagnostic  application ;  the 
speculum,  for  instance,  revealing  a  lesion  of  the  cervix  uteri,  enables 
the  surgeon  at  once  to  apply  his  remedy.  Thus  treatment  follows  upon 
the  track  of  diagnosis,  one  sitting  and  one  operation  serving  for  both. 

Here  then,  as  in  medicine  generally,  our  first  indication  of  the  di- 
rection in  which  we  have  to  look  for  the  disease  which  causes  the 
patient  to  complain,  lies  in  the  disturbance  of  function.  We  have  then 
to  consider  what  these  functions  are.  The  first  in  importance,  because 
it  is  continued  with  occasional  interruptions  throughout  the  period  of 
active  sexual  life,  is  menstruation.  The  other  functions  are  incidental 
to  married  life  only ;  these  are  the  relation  to  the  other  sex,  pregnancy 
and  lactation. 

Most  of  the  diseases  which  attack  the  ovaries  and  uterus,  whether 
j)rimary  or  secondary,  entail  some  disturbance  in  the  menstrual  func- 
tion. The  flow  is  diminished  or  in  excess,  or  its  periodicity  is  de- 
ranged. It  is  attended  with  pain  in  the  pelvic  organs  and  other 
nervous  phenomena. 

We  shall  discuss  the  history  of  amenorrhoea,  menorrhagia,  and  dys- 
menorrhoea  hereafter.  Our  object  now  is  simply  to  determine  the  con- 
ditions which  suggest  local  examination.  In  the  great  majority  of 
cases  of  amenorrhoea  in  single  women,  no  local  exploration  is  necessary ; 
but  in  some  cases  it  becomes  imperative  :  for  examj^le,  amenorrhoea  is 
sometimes  presumptive  only — that  is,  the  secretion  takes  place,  but 
owing  to  some  imperfection  of  structure  it  is  retained  in  the  cavity  of 
the  uterus  or  vagina.  This  may  be  called  oceult  menstruation.  The 
suffering  becomes  urgent  in  the  highest  degree,  and  nothing  short  of 
an  operation  which  shall  liberate  the  retained  secretion  will  save  the 
patient.  Some  cases  again  of  suppressed  menstruation,  leading  to 
effusion  of  blood  behind  the  uterus,  setting  up  circumscribed  perito- 
nitis, and  displacing  the  uterus  so  as  to  press  upon  the  bladder,  may 
cause  retention  of  urine.  Here  again  local  examination  is  imperative. 
This  may  be  said  of  every  case  of  retention  of  urine.     In  almost  every 


68  INDICATIONS    FOR    EXAMINATION. 

case  of  retention  of  urine  in  women  the  cause  is  external  to  the  bladder, 
and  in  the  great  majority  it  is  due  to  some  disease  or  displacement  of 
the  uterus. 

Menorrhagia  is  a  relative  term;  that  is,  some  women  lose  much 
more  than  the  average  without  suiFering  in  health ;  but  whenever  the 
loss  continues  profuse,  obviously  entails  anaemia  and  general  debility, 
and  persists  in  spite  of  internal  remedies,  local  examination  is  clearly 
necessary.  We  shall  often  find  a  sufficient  local  cause  in  polypus, 
tumor,  inflammation,  congestion,  hypertrophy,  displacement,  or  malig- 
nant disease,  all  of  which  conditions  require  local  treatment. 

When  we  come  to  study  the  history  of  dysmenorrhoea  we  shall  find 
abundant  proof  of  the  almost  constant  association  of  this  disorder  with 
a  mechanical  condition  of  the  uterus  impeding  the  easy  performance 
of  the  function.  So  long,  however,  as  the  distress  does  not  clearly  affect 
the  general  system,  so  long  as  it  does  not  exceed  endurable  bounds, 
and  if  it  appears  to  be  moderated  by  general  remedies,  it  is  not  neces- 
sary to  examine ;  but  in  the  contrary  event,  examination  should  not 
be  long  postponed.  To  postpone  examination  is  to  postpone  discovery 
of  the  cause  and  effective  treatment.  This  is  more  especially  impera- 
tive in  the  case  of  a  married  woman  in  whom  dysmenorrhoea  is  com- 
plicated with  "  dyspareunia  "  and  sterility.  Abortion,  if  not  primarily 
depending  upon  some  local  disease  or  displacement  of  the  uterus,  is  so 
very  likely  to  be  followed  by  some  such  condition  that  an  examination 
should  be  instituted.  If  a  sanguineous  discharge,  even  periodical,  re- 
sembling -menstruation,  goes  on  during  lactation,  especially  if  it  be 
excessive  in  quantity,  and  attended  by  leucorrhoeal  discharge,  it  may 
be  almost  confidently  predicated  that  there  exists  some  uterine  disorder 
requiring  local  treatment. 

I  have  used  a  new  word,  "  Dyspareunia."  It  is  incumbent  upon 
every  one  who  coins  a  new  word  to  explain  its  meaning  and  to  justify 
the  innovation.  Just  as  the  word  "  dysmenorrhoea  "  has  been  coined 
in  order  to  express  compendiously  the  condition  of  difficult  or  painful 
menstruation;  just  as  "dyspepsia"  is  used  to  signify  difficult  or  pain- 
ful digestion, — we  want  a  word  to  express  the  condition  of  difficult  or 
painful  performance  of  the  sexual  function.  Such  a  word  would  be 
convenient  in  many  ways.  It  would  enable  us  to  avoid  the  longer  and 
coarser  forms  in  use,  by  substituting  a  single  word  at  once  euphonious, 
expressive,  and  in  harmony  with  medical  language.  After  consulting 
with  my  colleague,  Dr.  W.  H.  Stone,  whose  high  classical  attainments 
give  authority  to  his  advice,  I  have  determined  to  adopt  the  word 
"  dyspareunia."  It  is  derived  from  durrr^dp^woc,  a  word  used  in  this 
sense  by  Sophocles.  However  disagreeable  the  topic  may  be,  it  is  im- 
possible to  escape  reference  to  a  function  so  important.  Dyspareunia 
in  the  female  is,  perhaps,  the  most  absolute  of  all  the  indications  of 
local  malformation  or  disease.  It  calls  the  most  imperatively  for  local 
examination  as  to  its  cause.  In  its  milder  forms  it  may  make  the 
sufferer's  life  a  course  of  physical  and  mental  wretchedness ;  in  its 
severe  forms  it  virtually  unsexes  her ;  and  in  any  form  it  may  lead  to 
the  most  disastrous  social  calamities. 

Taking  this  condition,  dyspareunia,  as  a  symptom  of  disordered 


INDICATIONS    FOE    EXAMINATION.  69 

function,  we  shall  be  astonished,  when  we  proceed  to  direct  examination 
of  the  organs  concerned,  at  finding  how  many  those  causes  may  be,  and 
what  a  wide  field  of  pathological  inquiry  is  associated  with  it.  For 
example,  there  may  be  original  defect  or  malformation ;  there  may  be 
obstructing  tumors  or  growths,  inflammation,  dislocation  or  altered  form, 
disordered  innervation.  In  short,  almost  every  disease  to  which  the 
sexual  organs  are  liable  may  entail  dyspareunia  for  one  of  its  conse- 
quences ;  and  in  not  a  few  of  these  diseases  disregard  of  this  symptom 
may  entail  positive  danger. 

The  existence  of  certain  discharges,  such  as  blood,  under  conditions 
of  quantity  and  times  of  occurrence  which  distinguish  it  from  normal 
menstruation,  mucous,  purulent,  albuminous,  aqueous,  fleshy,  or  mem- 
branous, if  at  all  protracted,  point  clearly  to  some  local  disorder  as 
their  origin  which  requires  direct  exploration. 

Then  there  are  some  subjective  signs,  as  'pain,  lumbo-dorsal,  iliac, 
pelvic,  or  crural,  and  a  sense  of  bearing  down  or  pressure  upon  the 
rectum  or  bladder,  entailing  disorder  in  the  function  of  these  organs. 
These,  especially  if  connected  with  abnormal  discharges  and  other 
symptoms,  call  distinctly  for  local  investigation. 

Then  we  must  observe  the  constitutional  or  remote  effects  of  the  fore- 
going conditions.  Disorder  of  the  pelvic  organs  seldom  goes  on  long 
without  entailing  anaemia,  disordered  digestion,  hypersesthesia,  neural- 
gia, or  other  manifestations  of  nervous  derangement  or  prostration. 
When  these  conditions  are  observed  in  association  with  marked  signs 
of  derangement  of  function  of  the  pelvic  organs,  the  necessity  for  ex- 
ploring the  physical  state  of  these  is  as  clear  as  is  that  of  examining 
the  state  of  the  heart  or  lungs  when  these  organs  perform  their  function 
with  distress,  and  the  whole  system  suffers. 

Such,  then,  is  a  summary  view  of  the  conditions,  chiefly  subjective, 
which  point  out  to  us  the  desirableness  of  instituting  direct  observation 
of  the  pelvic  organs.  This  direct  observation  commonly  enables  us  to 
analyze  the  groups  of  subjective  symptoms ;  to  determine  the  cause  and 
significance  of  each,  separately  and  collectively.  It  always  brings  to 
our  assistance  the  discovery  of  other  symptoms,  entirely  objective;  and 
almost  always  puts  it  in  our  power  to  apply  the  proper  treatment. 

The  special  study  of  the  significance  of  the  several  symptoms  of  pelvic 
disease,  subjective  and  objective,  will  be  traced  in  subsequent  chapters. 

We  have  ranked  discharges  amongst  the  most  pressing  indications 
for  instituting  local  exploration.  In  health  it  may  be  said  that,  except- 
ing the  monthly  discharge  of  menstruation,  there  is  no  escape  of  fluid 
from  the  vagina.  It  is  true  that  in  some  women  leucorrhcea  to  a  mod- 
erate extent  precedes  and  follows  the  menstrual  sanguineous  flow ;  it  is 
also  true  that  in  some,  leucorrhcea  continues  throughout  the  inter- 
menstrual period  without  in  any  obvious  way  entailing  local  or  consti- 
tutional distress.  Admitting  this,  the  rational  and  safe  rule  in  practice 
still  is,  to  examine  in  all  cases  where  a  discharge  at  all  copious  escapes 
from  the  vagina  attended  by  pain  and  signs  of  constitutional  impair- 
ment. This  may  be  stated  as  a  general  proposition  without  distinction 
as  to  the  nature  of  the  discharge.  But  we  will  now  examine  what  the 
discharges  are,  and  what  is  the  special  significance  of  each.     And,  in 


70  INDICATIONS    FOR    EXAMINATION. 

limine,  let  us  agree  upon  the  meaning  to  attach  to  two  words  which  we 
shall  frequently  have  occasion  to  use,  "  Secretion  "  and  "  excretion  " 
must  be  accurately  applied.  Following  Continental  custom,  I  shall 
use  the  word  "  secretion  "  to  distinguish  the  act  of  separation  of  the 
discharge  from  the  free  surface  of  the  organs;  and  the  word  "excre- 
tion "  to  distinguish  the  act  of  voiding  from  the  body  altogether.  To 
take  an  example :  the  menstrual  fluid  may  be  poured  out  from  the 
mucous  surface  of  the  Fallopian  tubes  and  uterus — that  is  secretion. 
The  escape  of  the  fluid  by  the  vulva  is  excretion.  Excretion  is  the 
natural  complement  of  secretion.  But  the  process  may  stop  short  at 
secretion — that  is,  the  secreted  fluid  may  be  retained.  Thus,  if  there 
be  occlusion  of  the  genital  canal  at  any  point  below  the  os  uteri  in- 
ternum, the  secreted  menstrual  fluid  will  be  shut  up  in  the  cavity  of 
the  uterus  and  in  the  Fallopian  tubes.  There  is  no  excretion,  and, 
therefore,  apparently  no  discharge. 

Taking  the  discharges  as  they  first  come  under  the  notice  of  the 
clinical  observer,  that  is,  after  their  excretion,  they  may  be  roughly 
classed  under  the  following  heads :  1.  Sanguineous.  2.  Mucous. 
3.  Purulent.  4.  Watery.  5.  Membranous.  6.  Solid  or  fleshy.  7.  In 
the  case  of  fistulous  opening  into  the  bladder  or  rectum,  urine  or  fseces 
may  escape.  8.  Then  there  are  foreign  matters,  fluid  or  solid,  which 
find  their  way  into  the  uterus  and  vagina  from  without.  Amongst 
these  may  be  mentioned  semen  distinguished  by  spermatozoa. 

If  we  limited  our  inquiry  to  the  examination  of  these  discharges 
when  excreted,  we  should  hardly  attain  to  any  more  precise  knowledge 
than  is  expressed  in  the  general  terms  by  which  we  have  designated 
them.  We  cannot  arrive  at  a  certain  knowledge  of  their  source,  or 
form  a  trustworthy  estimate  of  their  pathological  significance,  unless 
we  examine  minutely  the  organs  from  which  they  are  secreted. 

I  may  state  another  proposition :  most  of  the  diseases  of  the  uterus 
and  vagina  are  attended  by  discharges.  But  it  must  not  be  assumed 
that,  when  no  discharge  exists,  or  is  noticed  by  the  patient,  there  is  no 
disease.  Serious  disease  of  the  ovaries  and  uterus  may  exist  for  a  long 
time  without  being  attended  with  any  discharge.  And  still  more  fre- 
quently discharges  are  overlooked  by  the  patients,  but  become  obvious 
enough  on  examination. 

Of  all  the  discharges,  the  only  one  which  can  be  called  strictly  nor- 
mal is  blood ;  and  this  is  only  normal  within  certain  conditions  of  cir- 
cumstance, time,  and  quantity.  Previous  histological  study  will  lend 
the  most  material  aid  to  direct  observation  in  determining  the  sources 
and  significance  of  discharges.  We  may  start  from  the  proposition 
that,  with  one  or  two  rare  exceptions,  all  the  discharges  we  have  to 
deal  with  come  from  mucous  membrane,  or  at  least  from  organs  nor- 
mally clothed  by  mucous  membrane.  The  discharges  will  generally 
bring  with  them  some  of  the  distinctive  elements  of  the  part  of  the 
mucous  tract  from  which  they  are  secreted.  Hence  microscopical  ex- 
amination of  a  discharge  will  almost  always  reveal  epithelium  cells 
which  tell  their  own  tale  as  to  the  region  they  come  from.  In  this  way 
we  can  distinguish  uterine  mucus  from  vaginal. 

The  whole  genital  tract  secretes  mucus.     It  is  only  when  excessive 


THE  SECRETIONS  OF  THE  UTERUS,  ETC. 


71 


in  quantity,  or  altered  in  quality,  that  the  secretion  of  mucus  acquires 
a  pathological  significance. 

The  natural  mucous  secretions  are : 

1.  A  whitish  mucus  from  the  Fallopian  tubes  and  cavity  of  the 
uterus  proper.  This  probably  comes  principally  from  the  uterine 
glands.  It  has  an  alkaline  reaction.  It  is  distinguished  under  the 
microscope  by  the  presence  in  it  of  columnar  ciliated  epithelium  cells. 
In  health  this  secretion  is  moderate  in  quantity,  and  attracts  no  atten- 


FlG.  27. 


Fig.  27. — Mucous  discliarge  from  the  healthy  cervix  uteri,  taken  from  the  mucous  cryiits.  The 
mucous  corpuscles  are  arranged  in  strings  by  the  viscidity  of  the  plasma  in  which  they  are  en- 
tangled.   (After  Tyler  Smith  and  Hassall.) 

Fig.  28. — Mucous  corpuscles,  epithelial  particles,  and  oil-granules  from  cervical  leucorrhoea.  (After 
Tyler  Smith  and  Hassall.) 

tion.  But  in  the  condition  known  as  uterine  catarrh  it  is  very  abun- 
dant, sometimes,  especially  in  aged  women,  accumulating  in  the  uterine 
cavity,  and  causing  colic  pains  to  expel  it.  The  uterine  mucous  mem- 
brane may  also  be  stimulated  to  excessive  secretion  by  gonorrhoeal 
infection  spreading  from  the  vagina. 

2.  A  transparent  viscid  mucus  in  the  cervix  uteri.  This  is  also  alka- 
line. It  consists  chiefly  of  mucous  corpuscles,  caudate  corpuscles, 
minute  oil-globules,  and  occasionally  dentated  epithelium,  all  entangled 
in  a  thick  tenacious  plasma  (see  Fig.  27).  In  health  this  secretion  is 
rarely  formed  in  such  excess  as  to  appear  externally,  but  it  is  almost 
always  found  in  the  cervix  filling  up  the  canal.  The  mucous  plug 
thus  formed  is  washed  away  at  each  menstrual  flow ;  it  exists  gene- 
rally throughout  pregnancy.  Its  uses  are  probably  to  shut  off  the  ute- 
rine cavity,  so  as  to  protect  it  from  external  agencies,  and  to  form  a 
suitable  medium  for  the  passage  of  the  spermatozoa.  At  the  begin- 
ning of  labor  this  secretion  is  formed  in  increased  copiousness,  and 
serves  to  lubricate  the  passages,  and  to  facilitate  their  dilatation.  In 
certain    morbid   conditions  the  cervical   glandular  structure  also  ac- 


72 


VAGINAL,    DISCHARGES. 


quires  extraordinary  activity,  and  then  the  proper  cervical  mucus 
assumes  the  character  of  a  discharge.  It  is  poured  in  large  quantity 
into  the  vagina,  so  freely,  indeed,  as  to  be  a  serious  drain  upon  the  sys- 
tem, and  a  source  of  weakness.  It  constitutes  the  most  frequent  form 
of  so-called  "  whites  "  or  leucorrhoea.  If  the  speculum  be  used  it  may 
be  seen  issuing  from  the  uterus  as  a  glairy,  albuminous  fluid,  re- 
sembling unboiled  white  of  egg.  This  exaggerated  secretion  is  almost 
always  the  consequence  of  inflammation,  more  or  less  acute,  of  the 
cervical  canal,  or  of  a  condition  analogous  to  catarrh  of  the  bron- 
chial or  intestinal  mucous  membrane. 

3.  A  mucus  consisting  of  plasma,  not  viscid,  but  containing  multi- 
tudes of  scaly  epithelium  cells.  This  comes  mainly  from  the  external 
surface  of  the  cervix  uteri,  labia  uteri,  and  the  fundus  of  the  vagina. 
It  is  of  acid  reaction.  The  proportion  of  epithelial  cells  to  that  of  the 
fluid  plasma  varies  considerably.  In  some  cases  the  fluid  part  is  so 
scanty  that  the  secretion  adheres  to  the  mucous  membrane,  covering 
the  OS  uteri  as  with  flakes,  or  a  layer  of  opaque  yellowish-white  friable 
membranous-looking  substance,  simulating  and  suggesting  diphtheria. 
It  often  adheres  in  the  form  of  a  thick  layer  upon  india-rubber  pessa- 
ries. Under  the  microscope  this  is  found  to  consist  almost  entirely  of 
scaly  epithelium  and  oil-globules.  In  other  cases,  the  plasma  being  a 
little  more  abundant,  the  secretion  looks  like  cream  or  pus.  But  in 
these  cases  the  microscope  reveals  the  same  constituents — namely,  scales 
of  epithelium.  These  forms  of  secretion  depend  upon  chronic  or  sub- 
acute inflammation  of  the  mucous  membrane — vaginitis,  not  necessarily 
accompanied  with  abrasion  or  ulceration.  The  puriform  mucus,  more  or 
less  opaque  and  viscid,  varying  in  tinge  from  creamy  white  to  yellow- 
ish or  light  green,  is  often  due  to  gonorrhoeal  infection,  or  to  suppura- 
tion from  surfaces  denuded  of  epithelium  and  granulating.     When  due 

to  gonorrhoeal  infection  the  mucous 
membrane  from  os  uteri  to  vulva 
is  swollen,  angry  red,  and  pain- 
ful, and  the  meatus  urinarius  ex- 
hibits the  same  characters.  The 
creamy  form  of  secretion  is  fre- 
quently found  during  pregnancy  on 
the  vaginal  portion  of  the  uterus. 
It  is  the  result  of  the  active  throw- 
ing ofl"  of  squamous  epithelium  due 
to  hypersemia. 

4.  The  remaining  or  lower  tract 
of  the  vagina  secretes  an  acid  mucus. 
Under  morbid  states  this  sometimes 
contains  pus-globules,  an  infuso- 
rium, the  Trichomonas  vaginalis  of 
Donne,  and  a  fungus,  the  Lepto- 
thryx  buccalis  of  Robin.  But  the 
parasites  are  really  mainly  due  to 
neglect  of  cleanliness.  Whitehead 
suggests  that  the  use  of  the  acid  of  the  vaginal  mucus  is  to  prevent  the 


Fig.  29. 


Epithelium  from  vaginal    leucorrhoea— (after 
Tyler  Smith  and  Hassall). 


LEUCOEEHCEA.  73 

coagulation  of  the  catamenial  fluid  in  the  vagina.  It  certainly  seems 
to  possess  the  property  of  coagulating  the  alkaline  mucus  coming  from 
the  cervix.  I  doubt  the  correctness  of  Whitehead's  theory.  It  is  im- 
portant that  the  blood  should  not  coagulate  in  the  uterus,  because  clots 
there  cause  severie  pain  and  congestion,  and  are  apt  to  keep  up  hemor- 
rhage ;  but  a  clot  in  the  vagina  is  of  little  consequence.  Pus  stops 
coagulation  ;  so  does  mucus,  provided  the  proportion  of  blood  is  small. 
I  believe  it  is  the  normal  mucus  which  maintains  fluidity.  Whenever 
the  proportion  of  blood  is  greatly  in  excess  it  is  apt  to  coagulate. 

5.  There  is  a  clear  viscid  secretion  from  Bartholini's  glands,  which 
is  discharged  in  jets  during  copulation.  It  has  been  seen  to  escape  on 
irritation,  expelled  by  the  action  of  the  muscular  fibres  in  the  ducts. 
It  is  also  poured  out  freely  during  labor,  serving  to  lubricate  the 
vulva. 

6.  The  small  sebaceous  and  mucous  glands  of  the  vulva  and  labia 
majora  secrete  an  oily  mucus,  serving  for  lubrication.  This  is  some- 
times increased  in  quantity,  becoming  puriform. 

We  may  here  refer  very  briefly  to  one  or  two  other  points  connected 
with  mucous  discharges.  Donn6  says  when  the  acidity  of  the  vaginal 
mucus,  or  the  alkalinity  of  the  uterine  secretion,  is  morbidly  exagger- 
ated, the  spermatozoa  are  killed.  Hence  one  explanation  of  the  fre- 
quency of  sterility  when  there  is  inflammatory  disease  of  these  parts ; 
and  of  the  recurrence  of  pregnancy  when  the  disease  which  gives  rise 
to  the  morbid  secretions  is  cured. 


CHAPTER  yil. 

THE  SIGNIFICANCE  OF  LEUCOEKHCEA. 

The  preceding  summary  of  the  various  mucous  discharges  will  en- 
able us  to  estimate  more  accurately  the  history  of  leucorrrhoea. 

Although  leucorrhoea,  or  white  discharge,  is  generally  a  symptom 
only,  and  not  an  essential  morbid  condition,  it  is  necessary  to  study  its 
history  and  significance  separately  from  the  morbid  conditions  which 
produce  it.  In  a  considerable  number  of  cases  leucorrhoea  may  be 
regarded  as  a  catarrh  of  the  uterine  or  vaginal  mucous  membrane 
analogous  to  catarrh  in  other  mucous  tracts.  We  accordingly  see  not 
infrequently  that  leucorrhoea  is  cured  or  cures  itself  without  topical  treat- 


74  LEUCOEEHGEA. 

ment.  Nearly  twenty  years  ago  I  drew  attention  to  the  fact,  that  the 
uterine  mucous  membrane  was  subject,  like  other  mucous  membranes, 
to  epidemic  influence.  For  example,  M^hilst  in  some  this  influence 
would  affect  the  alimentary  canal  causing  diarrhoea ;  whilst  in  others, 
or  at  other  seasons,  it  would  cause  bronchitis  or  pneumonia ;  in  some 
women  it  would  give  rise  to  uterine  catarrh.  This  is  explained  in 
some  cases  by  sudden  changes  of  temperature,  checking  the  secretions 
of  the  skin ;  in  other  cases  the  direct  exposure  of  the  patulous  vagina  to 
draughts  of  cold  air,  as  from  using  an  open  privy,  has  appeared  to  be 
the  cause.  Certainly,  I  have  known  this  to  bring  on  pelvic  cellulitis 
and  peritonitis  in  patients  who  were  predisposed  by  recent  delivery,  or 
the  recent  performance  of  operations  on  the  pelvic  structures. 

In  the  article  "  Leucorrhoea"  in  the  Dictionnaire  des  Sciences  Medi- 
cales,  facts  illustrating  the  occasional  epidemicity,  are  referred  to  on  the 
authority  of  the  physicians  of  Breslau,  in  1702  ;  of  Morgagni  in  1710; 
of  Bassius  in  1730;  by  Raulin,  at  Paris,  in  1765 ;  and  by  Leake,  in 
England. 

Certain  forms  of  leucorrhoea  may  be  regarded  as  'physiological. 
Amongst  these  may  be  classed  that  excessive  secretion  of  mucus  which 
often  attends  the  hypersemia  of  pregnancy.  This  may  not  always  be  so 
profuse  as  to  escape  externally  and  attract  the  notice  of  the  subject ; 
but  it  is  rarely  absent,  and  by  the  speculum  it  is  seen  as  a  white  opaque 
secretion  of  creamy  consistency,  occupying  the  bag  of  the  fundus  and 
furrows  of  the  vagina.  This  secretion  also  consists  chiefly  of  epithe- 
lium scales.  If  the  vaginal  mucous  membrane  exhibit  with  this  secre- 
tion a  deep  violet-red  or  purple  color,  and  prominent  rugse  or  brain- 
like corrugations,  the  presumption  in  favor  of  pregnancy  is  great. 

This  form  of  leucorrhoea  requires  no  treatment. 

Another  form  of  leucorrhoea  which  may  be  called  physiological,  is 
that  pale  mucous  discharge  which  precedes  and  follows,  but  chiefly 
follows,  the  proper  menstrual  flow.  The  first  effect  of  the  flux  which 
takes  place  under  the  ovarian  nisus,  is  to  stimulate  the  glands  of  the 
uterus  to  increased  activity.  Hence  the  secretion  of  mucus  in  larger 
quantity,  which  sometimes  appears  externally  before  the  proper  men- 
strual blood  exudes  and  mixes  with  it.  This  increased  secretion  of 
mucus  goes  on  all  through  the  stages  of  menstruation,  and  persists 
for  a  while  after  the  exudation  of  blood  has  ceased.  This  post-men- 
strual leucorrhoea  may  be  likened  to  the  so-called  "  green-waters  "  of 
childbed.  It  flows  from  the  uterine  cavity,  as  does  the  proper  men- 
strual discharge. 

An  allied  variety  of  this  form  of  leucorrhoea  is  that  which  is  often 
witnessed  in  girls  who  do  not  menstruate  properly.  In  these  cases, 
leucorrhoea  is  the  substitute  for  the  healthy  menstrual  sanguineous 
flow.  It  is  evidently  the  result  of  an  imperfect  menstrual  molimen. 
It  is  provoked  by  ovulation  more  or  less  perfect.  It  may,  therefore, 
with  strict  justice  be  called  "  menstrual  leucorrhoea."  It  is  more  es- 
pecially prevalent  in  chlorotic  girls,  and  then  may  degenerate  into  a 
morbid  flux. 

What  has  been  said  about  physiological  leucorrhoea  sufficiently 
proves  that  inflammation  is  not  a  necessary  factor.     Indeed,  inflam- 


LEUCOREHGEA.  75 

mation  may  exist  without  leucorrhoea^  and  leucorrhoea  without  inflam- 
mation. In  the  great  majority  of  cases  of  leucorrhoea^  uterine,  vaginal, 
or  vulvar,  there  has  been  no  history  of  inflammation.  Those  forms 
which  are  more  directly  traced  to  inflammatory  conditions,  as  acute 
and  chronic  catarrhal  metritis,  will  be  more  conveniently  discussed 
when  describing  the  pathology  of  the  uterus. 

Leucorrhoea  may  be  the  expression  of  a  constitutional  diathesis. 
Thus  the  strumous  diathesis  is  known  to  be  commonly  attended  by  a 
tumid  development  of  the  mucous  membranes,  and  a  disposition  to 
glandular  engorgements.  Girls  and  women  possessing  this  diathesis 
are  frequently  the  subjects  of  leucorrhoea  without  showing  any  special 
alteration  of  the  genital  mucous  membrane.  But  occasionally  there  is 
a  distinct  tuberculous  condition  of  the  mucous  membrane.  When 
this  is  the  case,  the  attendant  leucorrhoea  is  peculiarly  intractable,  even 
incurable. 

Leucorrhoea  is  not  uncommon  in  women  suffering  from  tubercular 
disease  of  the  lungs. 

The  syphilitic  diathesis  produces  analogous  effects ;  and  that  not 
only  when  the  diathesis  has  been  acquired  by  primary  infection,  or 
throuo'h  the  o-estation  of  an  infected  ovum,  but  also  when  the  diathesis 
has  been  transmitted  hereditarily. 

The  gouty  and  the  rheumatismal  diathesis  are  described  by  some 
writers  as  disposing  to  leucorrhoea,  and  that  of  a  very  obstinate  form. 

In  certain  states  of  great  debility,  marked  by  anaemia  and  defective 
nutrition  of  the  tissues,  mucous  fluxes  are  easily  excited,  and  the  geni- 
tal mucous  tract  is  especially  prone  to  be  so  affected.  In  such  cases 
there  need  be  no  inflammation,  no  breach  of  surface,  no  abnormal 
growth.  The  coats  of  the  vessels,  the  tissues  of  the  mucous  mem- 
brane, the  muscular  structure  of  the  uterus  are  all  so  deficient  in  tone 
and  contractility,  and  the  blood  is  so  wanting  in  plasticity,  that  an 
exudation  of  the  watery  element,  mingled  with  mucous  secretion, 
readily  takes  place.  This  state  of  anaemia  may  be  induced  by  various 
causes,  as  acute  or  chronic  disease,  hemorrhages,  or  by  oversuckling. 
It  may  also  be  induced  by  town-life  and  unhealthy  occupations  pur- 
sued in  bad  hygienic  conditions.  Accordingly,  leucorrhoea  is  believed 
to  be  more  frequent  in  towns  than  in  the  country,  although  the  statis- 
tics cited  to  prove  this  position  are  by  no  means  free  from  fallacy. 
The  feeble,  relaxed  state  of  health  induced  in  Europeans  living  in 
tropical  climates,  is  certainly  often  attended  by  leucorrhoea ;  and  in 
this  we  see  another  example  of  the  relationship  between  leucorrhoea 
and  hemorrhage.  Thus,  I  have  known  instances  of  women  who 
always  suffered  from  leucorrhoea  whilst  in  India,  remain  free  whilst 
staying  in  England. 

Diet  has  been  supposed  to  have  some  influence  in  the  production  or 
promotion  of  leucorrhoea.  No  doubt  a  diet  deficient  in  nutritive 
power  may,  by  inducing  general  debility,  favor  the  occurrence  of 
leucorrhoea ;  and  it  is  equally  certain  that  a  good  nutritive  diet,  by 
imparting  tone  and  general  health,  will  tend  to  prevent  or  cure  leu- 
corrhoea ;  but  I  am  not  aware  of  any  jjrecise  observations  to  prove 


76  LEUCORRHGEA. 

that  any  particular  articles  of  food  have  a  distinct  or  specific  action  in 
promoting  leucorrhoea. 

Leucorrhoea  is  common  in  association  with  disorder  of  the  digestive 
organs.  Dyspepsia,  flatulence,  distension  of  the  stomach  and  abdomen, 
constipation  or  diarrhoea  are  frequently  observed.  To  determine  which 
was  the  antecedent  disorder  is  not  always  easy ;  but  this  much  is  cer- 
tain :  almost  all  the  dyspeptic  women  who  have  copious  leucorrhoea, 
and  in  whom  physicians  are  so  ready  to  explain  the  leucorrhoea  by  the 
disorders  of  digestion,  have  uterine  disease.  Leucorrhoea  rarely  lasts 
any  considerable  time  without  entailing  dyspepsia  and  mal-nutrition. 

Leucorrhoea,  however,  is  frequent  among  women  who  follow  seden- 
tary occupations,  and  in  whom  the  bowels  are  habitually  loaded.  I 
have  known  women  who  were  leading  a  fairly  active  life  always  sub- 
ject to  leucorrhoea  when  their  bowels  were  constipated.  The  same  con- 
dition favors  menorrhagia. 

But  after  making  every  allowance  for  the  influence  of  disordered 
digestion,  and  of  other  distant  or  indirect  factors  in  producing  leucor- 
rhoea, the  fact  remains  that  in  the  great  majority  of  instances,  after 
childhood,  lucorrhoea  is  dependent  upon  some  uterine  abnormality.  I 
may  repeat  what  I  have  already  said  that  almost  every  morbid  condi- 
tion of  the  uterus  is  liable  to  be  attended  by  discharge.  When  there 
is  acute  or  chronic  endometritis,  abrasion,  tumor,  polypus,  or  displace- 
ment, leucorrhoea  is  rarely  absent.  Hence  the  significance  of  leucor- 
rhoea as  a  symptom  pointing  to  uterine  disease. 

In  women  who  are  in  any  way  constitutionally  predisposed  to  leu- 
corrhoea slight  causes  will  provoke  it.  Excessive  exercise,  as  in  walk- 
ing, excess  in  sexual  indulgence,  the  wearing  a  pessary,  in  short,  almost 
any  local  irritation  is  sufficient.  "When  there  is  no  special  predisposi- 
tion, the  like  causes  long  acting  may  provoke  leucorrhoea.  The  pres- 
ence of  a  tumor  in  the  wall  of  the  uterus  attracting  an  undue  quantity 
of  blood,  the  chafing  of  a  polypus  against  the  walls  of  the  cervix  or 
vagina,  or  even  the  presence  of  a  hypertrophied  vaginal  portion  will 
seldom  fail  to  produce  leucorrhoea. 

The  division  of  leucorrhoea  into  uterine,  vaginal,  and  vulvae-,  as 
propounded  by  Donn6  and  Tyler  Smith,  is  based  not  less  on  clinical 
than  on  anatomical  foundation.  As  we  have  seen,  the  microscopical  and 
chemical  analysis  exhibit  distinctive  characters,  and  the  pathological 
history  too  is  often  different.  It  may  be  stated  as  a  general  proposition, 
one  admitting,  indeed,  of  numerous  exceptions,  that  vulvar  leucorrhoea  is 
more  peculiar  to  childhood,  vaginal  to  young  women,  and  cervical  and 
uterine  to  middle  and  advanced  age.  All  the  forms  may  coexist  in  the 
same  patient,  but  in  many  one  may  exist  alone.  This  is  especially  the 
case  wuth  the  vulvar  leucorrhoea  of  children.  It  is  also  often  true  of 
the  vulvar  leucorrhoea  attending  pruritus  in  aged  women.  The  char- 
acters of  the  discharge  in  vulvar  leucorrhoea  are  diflPerent  at  different 
ages.  Thus  in  children  in  whom  the  sebaceous  glands  are  not  yet  de- 
veloped the  discharge  is  serous  or  sero-purulent,  resembling  that  which 
results  from  eczema  of  the  skin.  At  puberty,  and  during  the  child- 
bearing  epoch,  the  same  kind  of  sero-purulent  secretion  may  exist,  but 
it  is  commonly  mingled  with  the  proper  secretions  of  the  vulvo-vagi- 


L  E  U  C  O  R  R  H  ffi  A.  77 

nal  glands  and  of  the  sebaceous  glands  which  are  at  the  acme  of  their 
development  at  this  time.  The  secretion  will  be  viscid,  unctuous,  giv- 
ing a  characteristic  cheesy  or  fishy  odor.  The  vulvar  leucorrhoea  of 
advanced  age  reverts  to  the  characters  of  infancy,  the  sebaceous  folli- 
cles having  in  great  measure  disappeared  from  atrophy. 

Vaginal  leucorrhoea  at  all  ages  consists  essentially  of  an  exaggerated 
formation  and  shedding  of  pavement-epithelium  scales  (see  Fig.  28). 
In  many  instances  a  great  part  of  the  fluid  element  of  the  vaginal  dis- 
charge arises  from  the  cervical  cavity. 

Cervical  leucorrhcea  is  most  frequent  in  the  childbearing  period.  It 
is  essentially  mucous,  and  exhibits  the  characters  seen  in  Figs.  27  and 
28.  TJtei'ine  leucorrhoea  or  catarrh  will  vary  in  character  according 
to  age.  During  the  childbearing  epoch  the  uterine  glands  contribute 
a  quantity  of  mucus  to  mix  with  the  epithelial  debris.  At  a  later  period 
the  epithelial  debris  assume  a  creamy  or  milky  consistence  from  fatty 
metamorphosis  and  the  admixture  with  a  serous  exudation.  In  all 
the  cases  pus  may  be  found  if  there  is  breach  of  surface,  as  from  ul- 
ceration and  granulation.  Uterine  and  cervical  leucorrhoea  is  a  fre- 
quent attendant  upon  dysmenorrhoea,  especially  of  that  form  which  is 
characterized  by  partial  retention.  If  there  be  atresia  or  narrowing  at 
the  OS  externum,  the  congestion  consequent  on  the  futile  attempts  of 
the  uterus  to  expel  its  contents  excites  to  increased  activity  of  the  uter- 
ine and  cervical  glands.  And  the  product  of  this  increased  activity 
finding  in  its  turn  difficult  escape,  tends  to  accumulate,  and  to  dilate 
the  cavities  of  the  cervix  and  body  of  the  uterus.  Thus  spasm  or  colic 
is  exerted,  and  the  mucous  accumulation  may  be  expelled  en  masse.  It 
is  in  this  way  we  account  for  the  frequently  intermittent  character  of 
leucorrhoeal  discharges. 

If  called  upon  to  describe  summarily  the  distinguishing  characters 
of  uterine,  vaginal,  and  vulvar  leucorrhoea,  we  might  say  that  the  first 
is  mucous,  the  second  epithelial,  and  the  last  sebaceous.  The  somewhat 
greasy  character  of  vaginal  leucorrhoea  is  mainly  attributable  to  the 
fatty  metamorphosis  of  the  epithelial  scales. 

The  leucorrhoea  of  children  deserves  careful  attention.  The  occur- 
rence of  a  discharge  being  often  attended  with  local  irritation,  the  child 
is  likely  to  resort  to  friction  or  scratching  for  relief.  The  redness  and 
tumefaction  thus  added  to  the  discharge  are  very  apt  to  excite  suspi- 
cions of  foul  play,  and  thus  to  lead  to  false  accusations.  It  is,  there- 
fore, in  the  last  degree  important  to  bear  in  mind  the  conditions  under 
which  leucorrhoea  in  children  may  arise,  lest  we  too  hastily  adopt  the 
suspicions  that  may  be  suggested  to  us  by  others. 

Many  years  ago^  I  made  the  observation  that  acute  exanthemata,  as 
small-pox  and  scarlatina,  which  we  know  affect  the  whole  mucous  tract, 
as  well  as  the  skin,  occasionally  left,  as  sequelae,  vaginitis,  and  leucor- 
rhoea, even  in  children.  Graves,  Scanzoni,  and  others  have  confirmed 
this  observation. 

Strumous  children  are  especially  subject  to  vaginal  and  vulvar  leu- 
corrhoea.    Irritation  of  the  rectum  as  from  ascarides,  commonly  pro- 

1  Medical  Gazett-e,  1850. 


78  LEUCORRHCEA. 

duces  it.  In  children  of  this  taint  it  alternates  with,  or  accompanies 
crusta  lactea  or  impetigo,  herpes,  eczema.  It  is  said  to  be  due  to  the 
irritation  of  teething,  but  this  I  have  not  noticed,  except  in  cases  where 
a  strumous  diathesis  offered  a  sufficient  explanation. 

In  many  cases  the  vulvar  leucorrhoea  in  children  is  kept  up  by 
neglect  of  cleanliness. 

The  principal  features  which  would  favor  the  conclusion  that  leucor- 
rhoea observed  in  a  child  is  due  to  a  criminal  attempt,  are:  marks  of 
contusion,  swelling,  ecchymosis,  turgescence  of  the  vessels  of  the  vulva 
and  vagina ;  extreme  rapidity  and  intensity  of  the  disease.  If  there 
was  gonorrhoeal  infection,  then  there  will  be  a  purulent  discharge, 
greenish-yellow  in  color,  copious  enough  to  bathe  the  external  parts 
and  to  stain  the  linen,  thick  enough  when  drying  to  glue  together  the 
lips  of  the  vulva,  and  flowing  equally  from  the  vagina  and  urethra. 
This  urethral  complication  is  especially  important,  for  according  to 
Tardieu,  violence  done  to  the  sexual  organs  of  a  child  by  a  healthy  man 
may  produce  an  inflammation  as  acute,  and  a  discharge  as  copious  and 
thick,  as  that  done  by  a  man  affected  with  gonorrhcea. 

It  is  obvious  from  the  foregoing  considerations  that  the  greatest  pos- 
sible circumspection  is  necessary  before  committing  one's  self  to  the 
expression  of  a  positive  opinion  as  to  the  origin  of  an  apparently  viru- 
lent discharge  in  a  child. 

A  question  which  has  attracted  some  attention  is  this :  Does  the 
leucorrhceal  discharge  by  contact  with  the  mucous  membrane,  on  whose 
surface  it  is  retained  or  over  which  it  flows,  exert  any  irritating  or 
injurious  action?  We  frequently  find  associated  with  leucorrhoea 
patches  of  the  surface  of  the  vaginal  portion  denuded  of  epithelium, 
small  ulcerations  they  may  be  called,  a  state  of  tumefaction,  even  red- 
ness. Are  these  caused  by  the  leucorrhoea?  In  the  majority  of  cases 
they  assuredly  are  not.  They  mostly  take  their  origin  in  those  pro- 
cesses which  produced  the  leucorrhoea  as  well.  They  are  frequently 
the  consequence  of  labor  or  abortion,  during  which  processes  the  cervix 
uteri  undergoes  severe  injury.  It  is  conceivable,  however,  that  long- 
continued  maceration  of  a  mucous  membrane  in  leucorrhceal  fluid  may 
effect  some  alteration,  as  softening  of  its  tissue,  and  this,  leading  to 
excessive  exfoliation  of  its  epithelial  layer,  may  facilitate  the  denuda- 
tion of  the  basement  layer.  This  would  be  especially  likely  to  happen 
under  the  influence  of  any  unusual  accidental  irritation,  as  excessive 
walking,  or  sexual  indulgence.  Dr.  Tyler  Smith,  however,  submitted 
that  sometimes  the  discharge  possessed  decided  acrid  or  irritating  proper- 
ties, capable  of  directly  inducing  ulcerations,  granulations,  follicular 
cysts,  and  other  disorders.  That  is,  he  looked  upon  leucorrhoea  as  a 
primary  disease.  This  opinion  appears  to  me  to  want  confirmation. 
It  is  intelligible  that  the  permanent  increased  turgidity  of  vessels,  and 
the  consequent  altered  condition  of  the  tissues  attending  habitual  leu- 
corrhoea, may  in  the  end  entail  the  alterations  named ;  but  this  is  a  dif- 
ferent thing  from  their  direct  production  by  the  irritating  property  of 
the  discharges. 

If  fluid  be  retained  inside  the  cavity  of  the  uterus,  then  it  will  act 
mechanically  according  to  hydrostatic  laws.    It  then  excites  contractile 


LEUCOEEHCEA.  79 

efforts  of  the  uterus,  and  as  the  fluid  does  not  escape,  or  only  partially, 
the  equal  eccentric  pressure  of  the  fluid  against  the  walls  of  the  con- 
taining cavity  leads  to  the  dilatation  of  this  cavity.  Its  retention  on 
the  surface  of  the  mucous  membrane  would  also  interfere  materially 
with  the  performance  of  some  at  least  of  the  functions  of  this  mem- 
brane, as  for  example,  the  healthy  course  of  menstruation  and  the 
carrying  of  spermatozoa. 

There  is,  however,  reason  to  believe  that  the  sebaceous  secretion  of 
vulvar  leucorrhoea,  if  retained,  may  become  especially  offensive  and 
acrid,  and  keep  up  or  produce  an  inflammatory  state  of  the  tissues 
bathed  by  it.  Another  question  has  been  started :  Can  the  secretions 
classed  as  leucorrhoea  be  absorbed,  and  give  rise  to  constitutional  tox- 
aemia? I  content  myself  with  citing  the  question.  I  know  of  no 
precise  evidence  to  support  an  affirmative  answer.  There  is,  however, 
evidence  to  show  that  such  poisons  as  lead,  carbolic  acid,  chromic  acid, 
used  to  vaginal  surfaces  bared  of  epithelium  may  be  absorbed,  and  pro- 
duce their  specific  toxical  effects  on  the  system. 

It  is  also  certain  that  foul  secretions  retained  in  utero  may  be  taken 
up  into  the  uterine  veins  and  lymphatics,  and  give  rise  to  inflammation 
of  the  broad  ligaments,  peritonitis,  and  general  septicsemia.  This  is 
especially  the  case  in  the  puerperal  state  after  childbirth  at  term  and 
after  abortion,  and  also  from  cancerous  ulceration. 

But  these  facts,  although  proving  that  the  way  is  open  to  invasion, 
do  not  prove  that  the  system  is  ever  so  invaded  by  the  matter  of  ordinary 
leucorrhoea. 

The  diagnosis  of  the  kinds  of  leucorrhoea  from  each  other  is  some- 
times presumptive,  sometimes  almost  absolute.  It  is  generally  pre- 
sumptive in  cases  of  constitutional  disorder,  as  in  strumous  or  chlorotic 
girls,  in  whom  it  may  be  reasonably  inferred  that  there  is  no  uterine 
lesion,  and  in  whom  physical  exploration  is  not  pursued.  Diagnosis  is 
still  presumptive,  even  in  married  women  who  have  had  children,  until 
local  examination  is  made.  The  sources  of  the  discharge  may  Jbe  de- 
monstrated by  the  speculum.  We  may  actually  see  the  viscid  albu- 
minous secretion  coming  out  of  the  cervix.  So  again  in  the  chronic 
uterine  catarrh  of  old  age,  with  narrowing  of  the  os  externum,  and  in 
that  form  which  is  associated  with  dysmenorrhoea  from  retention,  we 
may  by  dilating  the  os  uteri  through  the  speculum  give  vent  to  the 
retained  secretion. 

Not  rarely,  leucorrhoea  exists  to  a  very  considerable  degree,  and  yet 
escapes  the  observation  or  attention  of  the  subject.  Women  not  seldom, 
when  questioned  as  to  the  existence  of  discharge,  say  they  have  none, 
whilst  examination  shows  copious  collection  of  mucous  fluids  in  the 
vagina,  and  issuing  from  the  cervix  uteri.  This  arises  from  the  patient 
either  not  being  conscious  of  the  escape  of  discharge,  or  being  careless 
about  it.  Sometimes  the  uterine  viscid  secretion  is  expelled  in  a  mass 
during  defecation,  and  thus  is  not  noticed. 

This  unobserved  leucorrhoea  might  be  called  "  occult  leucorrhoea." 
As  a  general  rule,  wherever  leucorrhoea  exists,  other  subjective  symp- 
toms are  present,  and  indicate  the  expediency  of  examination. 

Treatment. — The  principle  in  therapeutics  should  be,  first,  to  de- 


80  LEUCOERHCEA. 

termine  whether  the  leucorrhoea  depend  upon  or  be  complicated  with 
any  constitutional  diathesis  or  disorder.  If  this  be  determined  in  the 
affirmative,  our  treatment  should  first  be  directed  to  the  correction  of 
this  complication. 

The  treatment,  even  when  the  leucorrhoea  depends  upon  a  morbid 
diathesis,  is  general  and  local.  We  may,  for  example,  accomplish  a 
certain  amount  of  good  by  internal  remedies  and  hygienic  means,  in 
producing  improved  general  nutrition,  and  thus  in  improving  the  condi- 
tion of  the  tissues,  including  the  affected  mucous  membrane.  And  in 
some  cases,  perhaps  in  many,  these  general  measures  may  be  successful. 
This  is  especially  true  of  the  strumous  and  chlorotic  cases.  But  in 
others,  topical  applications  to  bring  about  a  healthier  tone  of  the  mu- 
cous membrane  will  be  extremely  useful,  if  not  indisjjensable.  We 
must  not  then  too  hastily  assume  that  the  treatment  of  strumous  or  of 
syphilitic  leucorrhoea  resolves  itself  into  the  constitutional  treatment  of 
the  struma  or  the  syphilis.  When  the  conjunctiva  is  affected  with 
catarrh  or  ofcher  form  of  inflammation  which  takes  its  rise  in,  or  some 
of  its  characters  from  a  strumous  or  syphilitic  taint,  we  find  the  most 
precious  adjuvant  in  topical  applications  to  the  eye.  So  of  the  skin. 
No  less  so  is  this  the  case  with  uterine  and  vaginal  leucorrhoea.  It 
would  unnecessarily  incumber  this  work  to  enter  with  any  degree  of 
detail  into  the  general  treatment  of  scrofula  or  syphilis.  If  I  pass  this 
by,  it  is  not  because  I  in  any  way  undervalue  its  importance.  General 
treatment  is  indispensable. 

Before  topical  treatment  is  adopted,  we  ought  to  form  a  fairly  pre- 
cise diagnosis  as  to  the  source  of  the  leucorrhoea,  that  is,  whether  it  be 
uterine,  vaginal,  or  vulvar.  It  is  for  want  of  attention  to  this  point 
that  vaginal  injections  are  found  to  be  so  often  useless.  Vaginal  in- 
jections fail,  because  they  do  not  touch  the  main  seat  of  the  disorder, 
which,  in  the  majority  of  cases,  is  in  the  uterus  itself.  But  although 
they  fail  to  cure,  they  may  be  useful  as  far  as  they  go.  In  constitutional 
leucorrhoea,  the  vaginal  mucous  membrane  as  well  as  the  uterine  is 
commonly  involved  ;  and  something  is  gained  if  we  improve  the  con- 
dition of  a  part  of  the  affected  tract.  There  is  therefore  sufficient  rea- 
son to  prescribe  them,  and  thus  to  enlist  the  patient  in  her  own  service. 
She  may  herself  manage  the  vaginal  injection.  For  the  topical  treat- 
ment of  the  uterine  mucous  membrane  she  must  have  recourse  to  her 
physician. 

The  most  useful  and  convenient  topical  applications  in  strumous 
and  most  other  forms  of  leucorrhoea  are  astringent  liquids.  Amongst 
these,  acetate  of  lead,  sulphate  of  zinc,  sulphate  of  alumina,  decoction  of 
oak-bark,  solutions  of  tannin. 

The  topical  applications  best  suited  for  the  interior  of  the  uterus  are 
sulphate  of  zinc,  nitrate  of  silver,  sulphate  of  alumina,  iodine.  The 
best  mode  of  applying  these  will  be  described  hereafter.  (See  Chapter 
XV.) 

In  the  case  of  syphilitic  taint  the  same  means  are  useful,  but  in  ad- 
dition I  commonly  use  the  iodide  of  mercury  ointment,  introduced  by 
means  of  the  ointment-carrier  I  have  contrived  for  the  purpose.  (See 
Chapter  XV.) 


LEUCOERHCEA.  81 

In  the  strumous  leucorrhcea  of  childreu,  cod-liver  oil  and  iron  are  of 
signal  service. 

The  second  indication  is,  if  we  discover  any  local  disease,  as  a  tumor, 
a  polypus,  displacement,  abrasion,  congestion,  hypertrophy,  to  en- 
deavor to  remove  this  cause  or  complication. 

The  third  indication  is,  in  the  event  of  our  detecting  no  constitutional 
diathesis  or  local  disease,  to  treat  the  leucorrhoea  as  an  independent 
disease,  if  the  discharge  be  excessive  or  entailing  obvious  local  distress 
or  general  weakness.  In  this  class  of  cases  we  should  begin  by  correct- 
ing any  disorder  of  the  digestive  organs.  We  should  be  especially 
careful  to  regulate  the  action  of  the  bowels,  to  remove  and  to  prevent 
the  accumulation  of  faeces  in  the  lower  bowel.  We  should  then  en- 
deavor to  restore  the  general  tone  and  strength  by  good  diet,  tonics, 
and  exercise.  Amongst  the  remedies  most  useful  are  strychnine,  iron, 
quinine,  and  arsenic.  The  last  is  often  remarkably  efficacious  in  leu- 
corrhoea depending  upon  debility.  Local  remedies,  as  alum  or  zinc 
injections,  are  often  useful  adjuncts;  but  in  young  women,  in  whom 
the  presumption  is  against  any  morbid  condition  of  the  mucous  mem- 
brane, they  will  be  generally  unnecessary,  and  for  other  reasons  it  is 
desirable  to  avoid  them. 

Balsamic  medicines,  especially  turpentine,  are  often  very  useful,  and 
now  that  they  can  be  given  in  capsules,  or  "  pearls,"  the  chief  objection 
to  their  use  is  overcome.  Courty  speaks  highly  of  the  advantage  to  be 
derived  from  tar-water  mixed  with  the  wine  drunk  at  meals.  It  is 
made  palatable  at  first  by  mixing  with  seltzer-water.  The  same  excel- 
lent author  extols  hydrotherapeutics.  In  the  chronic  forms  of  leucor- 
rhoea cold  water  in  every  form,  as  full  baths  or  hip  baths,  produces  the 
best  results.  It  is  at  the  same  time  the  best  revulsive  and  the  best 
tonic. 

In  this  chapter  I  have  attempted  to  give  merely  a  general  account 
of  leucorrhoea,  regarding  it,  as  for  practical  purposes  it  often  is  regarded, 
as  a  distinct  pathological  condition.  Leucorrhoea,  as  a  symptom  de- 
pendent upon  morbid  conditions  of  the  uterus  and  vagina,  will  be  in- 
cidentally described  as  a  part  of  the  history  of  these  several  morbid 
conditions. 

The  watery  and  purulent  discharges  might  not  inaccurately  be  in- 
cluded under  the  common  head  of  "  Leucorrhoea."  But  I  have  thought 
it  more  useful  to  describe  them  in  distinct  chapters. 


82  DISCHARGES    OF    AIR. 


CHAPTER  VIII. 

DISCHAEGES  OF  AIR. 

Air  may  get  into  the  vagina,  if  not  into  the  uterus,  in  the  non-preg- 
nant state.  In  the  normal  condition  the  walls  of  the  vagina  are  main- 
tained in  perfect  contact,  and  no  air,  or  probably  very  little,  is  admitted. 
But  where  the  parts  are  greatly  relaxed,  the  vulva  open,  as  when  the 
perineum  is  torn,  the  lower  part  of  the  vagina  is  no  doubt  exposed  to 
the  contact  of  air,  but  the  very  condition  of  patency  prevents  the  re- 
tention of  the  air  to  such  a  degree  as  to  lead  to  its  escape  in  perceptible 
volume.  Air  also  penetrates  where  too  large  a  pessary  is  worn,  which 
keeps  the  vaginal  walls  apart.  But  under  peculiar  circumstances  air 
enters  in  large  quantity,  to  be  expelled  with  noise.  Dr.  George  Harley 
details'  a  curious  case,  in  which  he  carried  out  decisive  experiments,  to 
prove  the  correctness  of  the  diagnosis,  A  pluripara  frequently  expelled 
air  from  the  vagina  with  a  loud  noise.  It  was  ascertained  that  no  con- 
nection existed  between  the  rectum  and  vagina.  Dr.  Harley  took  a 
full-sized  male  catheter,  to  which  was  attached  a  long  india-rubber  tube 
with  a  stopcock  at  the  other  end.  The  catheter  was  introduced  into 
the  uterus,  the  end  of  the  tube  wdth  the  stopcock  being  placed  in  a 
tumblerful  of  water.  No  air  escaped  when  the  instrument  was  in  this 
position ;  but,  on  placing  the  open  end  of  the  catheter  in  the  vagina, 
an  instantaneous  discharge  of  gas  took  place.  The  water  was  found  to 
be  sucked  up  through  the  tube  into  the  vagina.  It  was  found  that  the 
vagina  sucked  in  and  expelled  the  air  by  spasmodic  action.  It  was 
further  observed  that  the  abdominal  muscles  assisted  in  the  suction  pro- 
cess. The  uterus  was  completely  retroverted.  This  displacement  being 
remedied,  and  the  health  improved  by  tonics,  a  cure  ensued.  Dr. 
McClintock  says  :^  "  Two  or  three  women  who  had  prolapse  of  the 
w^omb  have  told  me  that  soon  after  getting  up  in  the  morning  they  have 
been  conscious  of  the  escape  of  air  from  the  vagina.  The  vagina  was 
enlarged,  the  lower  part  of  the  uterus  hypertrophied.  There  was  no 
fistula ;  the  air  came  from  without." 

If  we  observe  the  vagina  when  the  duck-bill  speculum  is  applied, 
the  movements  of  rise  and  fall  under  the  influence  of  the  rise  and  fall 
of  the  diaphragm  are  seen.  Dr.  Adolph  Rasch  has  investigated^  these 
phenomena  with  great  care.  He  says,  if  a  multipara,  whose  genitals 
are  normal,  be  placed  on  her  back,  with  the  thighs  flexed  and  abducted, 
and  the  vaginal  orifice  closed,  movements  caused  by  respiration  are 
seen,  but  no  air  enters.  In  the  lateral  position  the  same  thing  is  ob- 
served even  if  the  vagina  is  lax,   and   even   when   the  perineum   is 

1  "Obpletrical  Transactions,"  1863.  2  "Diseases  of  Women,"  p.  54. 

2  "  Obstetrical  Transactions,"  1870. 


WATERY    DISCHARGES.  83 

ruptured.  When  the  patient  is  placed  in  the  prone  position,  or  on 
all-fours,  if  the  vulva  be  open,  air  will  enter,  because  the  intestines 
falling  downwards  by  gravity  causes  a  vacuum.  Under  this  condition 
violent  exertion  may  expel  air,  giving  rise  to  vaginal  flatus.  If  the 
abdomen  be  supported  by  the  hands  or  a  bandage,  no  air  enters. 

There  are  several  interesting  applications  of  this  knowledge.  It 
teaches  that  the  best  position  after  labor,  if  not  during  labor  also, 
is  the  dorsal  decubitus ;  that  the  same  position  is  also  best  in  the  case 
of  pelvic  abscess  or  hsematocele  discharging  into  the  vagina ;  and  that 
we  must  carefully  consider  this  respiratory  rise  and  fall  of  the  vagina 
when  selecting  pessaries.  It  is  by  turning  to  account  this  action  that 
we  derive  the  greatest  advantage  from  the  spoon  or  Sims's  speculum. 
The  blade  drawing  the  perineum  well  back,  whilst  the  semi-prone 
position  of  the  patient  favors  the  falling  forwards  of  the  abdominal 
viscera,  air  fills  the  vagina,  counteracts  the  effect  of  inspiration,  and 
thus  enables  us  to  get  a  good  view  of  the  os  uteri.  The  same  position 
also  greatly  aids  our  efforts  at  reducing  inversion  of  the  uterus,  and  in 
replacing  a  prolapsed  umbilical  cord.  On  the  other  hand,  in  most 
operations  upon  the  uterus  and  vagina,  where  it  is  of  importance 
to  bring  the  uterus  as  low  doM^n  near  the  vulva  as  possible,  the 
dorsal  position,  by  bringing  the  force  of  gravity  to  counteract  the  re- 
spiratory rise  of  the  uterus,  and  which  can  further  be  greatly  aided 
by  direct  pressure  by  an  assistant's  hand  above  the  symphysis  pubis j 
is  the  best. 


.  CHAPTER  IX. 

.^  THE  WATEET   DISCHAEGES. 

When  these  occur,  we  must  first  of  all  determine  the  presence  or 
absence  of  pregnancy.  It  is  no  uncommon  thing  that  discharges  of 
water,  more  or  less  profuse,  take  place  in  pregnant  women.  This  is 
the  "  hydrorrhoea  gravidarum."  Gushes  of  water,  quite  clear,  may 
occur  at  almost  any  time  during  pregnancy ;  but  they  are  more  fre- 
quent in  the  latter  months,  and  especially  in  the  last  month.  Happen- 
ing at  this  time,  they  are  commonly  taken  as  an  indication  of 
commencing  labor,  and  many  are  the  false  alarms  which  patient  and 
doctor  have  to  suffer  from  this  cause.  "  The  waters  have  broke,"  says 
the  nurse.  You  go,  as  in  duty  bound,  and  find  probably  the  os  uteri 
closed,  nothing  resembling  active  labor  pains.       What  are  you  to  do  ? 


84  WATERY    DISCHAEGES. 

If  you  wait  for  labor,  you  may  wait  for  a  week,  or  two  or  three 
weeks.  If,  on  examination,  by  ballottement,  you  find  the  child  still 
floats  in  the  uterus,  the  os  uteri  not  open,  and  no  active  pains,  you 
may  go  home  and  wait  in  peace  for  another  summons. 

What  is  the  source  and  nature  of  this  hydrorrhoea  gravidarum  ? 
Several  theories  have  been  expounded.  The  character  of  the  fluid 
differs  in  some  respects  from  that  of  liquor  amnii.  It  is  odorless, 
and  resembles  blood-serum  or  the  serous  fluid  effused  in  the  peritoneal 
sac.  Ruysch  and  Roederer  thought  it  came  from  rupture  of  lymphatic 
vessels,  or  of  hydatids  of  the  uterus ;  Bohmer  thought  it  escaped  from 
a  second  abortive  ovum  ;  Delamotte  and  Cruveilhier  that  it  came  from 
a  cyst  near  the  ovum ;  Deleurye,  Puzos,  ISTaegele,  and  Dubois,  that  it 
came  from  the  inner  surface  of  the  uterus,  being  secreted  externally  to 
the  ovum.  Dubois  says  it  is  the  result  of  loosening  of  the  membranes 
from  the  uterus  when  the  vessels  pour  out  serum.  Hegar  says  the 
source  is  the  uterine  glands  of  the  decidua.  Thus  he  describes^  the 
glands  of  the  mucous  membrane  as  being  found  in  the  decidua  at  the 
sixth  month  of  gestation,  and  argues  that  their  sudden  disappearance 
in  the  subsequent  months  is  improbable.  In  a  case  of  hydrorrhtea  he 
found  in  the  decidua  vera,  at  the  beginning  of  the  eighth  month,  an 
enormously  developed  glandular  body.  At  the  bottom  of  this  morbid 
growth  was  a  general  hypertrophic  condition  of  the  decidua  and  its 
glands.  These  gave  out  the  excessive  secretions.  In  a  case  related 
by  Dr.  Graef,^  repeated  discharges  took  place,  and  the  foetus  was  ex- 
pelled at  the  end  of  six  months.  The  membranes  were  very  delicate, 
and  openings  were  found  in  them.  In  this  case,  it  is  probable  that 
the  fluid  was  true  liquor  amnii.  In  another  case  the  patient  suffered, 
during  the  last  three  months,  from  repeated  watery  discharges ;  the 
uterus  rising  and  falling  with  the  gathering  and  escape  of  the  fluid. 
The  membranes  were  found  without  rent.  Graef  regarded  this  as  a 
case  of  catarrhal  hydrorrhoea. 

I  believe  there  are  various  sources.  In  some  cases  the  fluid  is  liquor 
amnii.  This  may  come  either  from  rupture  of  the  membranes ;  from 
rapid  transudation  under  pressure ;  from  rapid  formation  and  accumu- 
lation of  liquor  amnii  in  the  amnion  ;  or  from  the  bursting  of  a  cyst 
formed  between  the  amnion  and  chorion,  or  between  two  layers  of  cho- 
rion, the  proper  amniotic  sac  remaining  intact.  In  the  majority  of 
cases,  however,  the  fluid  is  not  amniotic.  It  is  then,  the  result  of  a 
rapid  secretion  from  the  uterine  glands  or  from  the  cervical  cavity.  In 
the  early  months,  whilst  there  is  still  a  free  space  between  the  decidua 
vera  and  the  decida  reflexa,  there  is  a  large  area  of  developed  glandu- 
lar surface. 

I  have  observed  a  puerperal  form  of  hydrorrhoea.  Thus  watery  dis- 
charges may  continue  for  a  month  or  longer  beyond  the  proper  lochial 
flow.  Generally  in  these  cases  the  water  is  dirty,  discolored,  occasion- 
ally stained  with  blood,  and  offensive.  The  most  common  cause  I 
have  found  to  be  the  retention  of  a  portion  of  placenta  or  of  clots  in  the 

'  "Monatsschrift  fiir  Geburtskunde,"  1863. 
2  "  Jenaische  Zeitschrift,"  1865. 


WATERY    DISCHARGES.  85 

uterus;  but  a  polypus  may  produce  like  results.  The  watery  dis- 
charges alternate,  but  not  always,  with  discharges  of  blood.  The  fluid 
may,  under  certain  conditions,  collect  in  considerable  quantity  in  the 
uterus,  so  that  the  organ  becomes  greatly  distended  before  the  collec- 
tion is  expelled  in  a  gush. 

Sometimes  watery  fluid  is  mingled  with  air,  constituting  physo- 
hydrometra.  This  is  also  a  puerperal  or  post-puerperal  condition,  and 
is  commonly  the  result  of  retention  of  some  portion  of  placenta  or 
membranes,  and  the  admission  of  air  into  the  uterine  cavity.  If  an 
examination  is  made  when  the  uterus  is  relaxed  after  labor,  especially 
if  the  hand  be  introduced  into  the  uterus,  the  vaginal  walls  are  sepa- 
rated from  their  usual  contact,  and  a  channel  is  formed  along  which 
air  easily  enters.  Merely  turning  on  the  side,  or  a  little  more  prone, 
will  often,  by  favoring  the  fall  of  the  uterus  forwards,  produce  a 
vacuum  into  which  air  will  rush.  This  is  one  reason  amongst  others 
why  I  am  unable  to  approve  of  the  abolition  of  the  old-fashioned 
binder,  which  some  people  would  condemn,  for  no  better  reason  that  I 
can  see  than  because  it  is  old-fashioned.  After  labor,  especially  in 
pluriparse,  the  abdominal  walls  are  so  relaxed  that  they  can  give  no 
support  to  the  uterus.  The  binder  does  temporary  duty  for  the  inert 
abdominal  walls.  The  history  of  physo-hydrometra  is,  I  believe,  this : 
a  portion  of  placenta,  membranes,  or  clots,  remains  in  the  cavity  of 
the  uterus  after  labor ;  some  air  gets  in  as  I  have  described ;  decompo- 
sition ensues,  and  the  gases  of  putrefaction  are  added  to  the  air  from 
without,  while  the  os  uteri  is  occluded  by  the  placental  or  blood-mass 
falling  over  it.  When  this  occurs,  there  is  invariably  hectic  or  irrita- 
tive fever;  peritonitis  and  septicaemia  commonly  attend ;  great  abdomi- 
nal pain.  The  enlarged,  distended  uterus  can  be  mapped  out  rising 
as  high  as,  or  higher  than  the  umbilicus ;  and  resonance  is  made  out 
on  percussion. 

One  condition,  the  result  of  impregnation,  often  leads  to  copious  and 
repeated  discharges  of  watery  fluid;  the  hydatidlform  degeneration  of 
the  chorion.  In  this  case  the  ordinary  signs  of  pregnancy  may  not  be 
present,  and  even  the  patient  herself  may  not  think  she  is  pregnant. 
There  is,  however,  always  evidence  of  enlargement  of  the  uterus,  and 
generally  great  pelvic  distress.  The  water  escapes  in  gushes  at  uncer- 
tain times;  it  .is  often  tinged  with  blood,  resembling  red  currant  water; 
it  has  not  the  offensive  odor  belonging  to  the  watery  discharges  of  can- 
cer; sometimes,  but  not  often  until  late  in  the  progress  of  the  case, 
cysts  will  be  found  swimming  in  the  water;  it  is  generally  expelled 
with  painful  uterine  contractions.  In  a  case  we  recently  had  in  St. 
Thomas's  Hospital,  the  nature  of  the  disease  v/as  not  at  first  suspected. 
There  was  some  abdominal  enlargement,  retention  of  urine  requiring 
the  catheter,  and  most  distressing  pelvic  pain  Avith  irritative  fever. 
The  OS  uteri  was  found  high  up  above  the  symphysis  pubis,  whilst 
behind  it  the  pelvic  cavity  was  filled  with  a  large,  rounded,  firm  mass, 
taken  to  be  either  the  retroverted  gravid  womb  or  a  fibroid  tumor. 
One  day  a  large  quantity  of  water,  blood,  and  a  mass  of  chorion-cysts 
were  expelled.     We  had,  in  fact,  the  condition  of  retroverted  gravid 


86  WATERY    DISCHARGES. 

womb  complicated  with  liydatidiform  or  cystic  degeneration  of  the 
chorion. 

Apart  from  pregnancy,  watery  discharges  are  often  of  grave  signifi- 
cance. During  and  after  the  climacteric  period,  the  most  frequent 
cause  is  some  form  of  malignant  disease,  especially  the  so-called  cauli- 
flower excrescence  of  the  uterus.  In  this  case  other  symptoms  will 
probably  point  to  the  seat  and  nature  of  the  disease.  The  fluid  dis- 
charge is  seldom  clear;  it  is  generally  turbid,  dirty,  often  tinged  with 
blood,  resembling  water  in  which  flesh  has  macerated;  it  contains 
shreds  or  flocculi  of  solid  matter,  the  proceeds  of  superficial  erosion  or 
necrosis  of  the  surface  of  the  diseased  growth,  and  is  almost  always 
of  a  peculiar  oifensive  odor.  It  often  alternates  with  hemorrhage. 
Local  exploration  will  place  the  nature  of  the  case  beyond  doubt. 
Another  form  of  malignant  disease  giving  rise  to  watery  discharges  is 
the  "oozing  excrescence  of  the  labia." 

But  we  must  remember  that  similar  discharges  may  take  place  from 
polypus  or  inversion  of  the  uterus.  Hence  we  have  another  example 
of  the  wisdom  of  not  pronouncing  a  diagnosis  until  we  have  made  an 
internal  examination.  Water  may  escape  in  large  quantity  from  the 
rupture  or  perforation  of  an  ovarian  cyst  in  the  vagina.  In  such  a 
case,  the  rapid  concurrent  diminution  of  the  abdominal  tumor  will  lead 
to  the  right  conclusion. 

Watery  discharge  may  be  urine  escaping  from  a  vesico-vaginal  fistula. 
The  character  of  the  fluid  and  other  circumstances  seldom  fail  to  estab- 
lish the  exact  nature  of  the  case. 

Under  certain  conditions  of  the  mucous  membrane  of  the  uterus, 
more  especially  of  the  cervix,  copious  secretion  of  watery  fluid  may 
take  place  rapidly.  I  believe  this  chiefly  occurs  when  the  mucous 
membrane  is  hypertrophied.  In  this  case  the  numerous  glands  are 
probably  also  hypertrophied,  and  acquire  a  greatly-increased  activity. 
It  will  be  remembered  that  all  the  mucous  membranes  at  times  dis- 
charge large  quantities  of  watery  fluid.  Thus  the  mouth  is  the  seat  of 
ptyalism,  the  stomach  of  pyrosis,  the  intestinal  canal  of  diarrhoea.  It 
is  rational  to  infer  that  causes  analogous  to  those  which  induce  watery 
secretion  from  the  mucous  membranes  in  these  organs,  may  induce  the 
like  event  in  the  mucous  membrane  of  the  genital  tract. 


PURULENT    DISCHAEGES.  87 


CHAPTER  X. 

THE  PUEULENT  DISCHARGES. 

Some  purulent-looking  discharges  are  in  reality  mucous,  the  appear- 
ance being  due  to  epithelium-cells,  not  to  pus-globules.  When  pus- 
globules  in  large  proportion  are  found,  they  indicate  generally  a  breach 
of  continuity  of  the  mucous  surface — that  is,  a  granulating  or  ulcerated 
surface.  When  pus  escapes  in  quantities,  suddenly  at  intervals,  and 
sometimes  by  continuous  draining,  the  source  probably  is  an  abscess 
whose  seat  is  outside  the  uterus  or  vagina,  as  in  what  is  called  pelvic 
cellulitis,  opening  into  the  vagina.  In  such  a  case  examination  by  touch 
internally,  and  externally  in  the  iliac  regions,  will  reveal  the  extra- 
uterine disease.  The  uterus  will  be  felt  set  fast  by  surrounding  firm 
plastic  effusion.  The  os  uteri  will  generally  be  found  in  the  centre  of 
the  pelvis,  low  down,  or  inclined  to  one  side,  if  the  pelvic  peritonitis 
is  chiefly  unilateral.  This  position  of  the  os  uteri  distinguishes  pelvic 
peritonitis  from  retro-uterine  hsematocele,  which  pushes  the  os  uteri 
forwards  close  behind,  and  sometimes  above  the  symphysis  pubis,  and 
which  may  also  be  attended  by  suppuration. 

A  suppurating  ovarian  cyst  may  contract  adhesion  with  the  roof  of 
the  vagina,  and  form  a  fistulous  perforation  through  which  pus  may 
escape. 

I  have  now  under  my  care  a  case  in  which  pus  is  voided  by  the 
vagina,  the  origin  of  which  is  an  abscess  in  the  left  hypochondriac 
region  opening  into  the  intestine,  and  which  at  a  lower  part  has  formed 
a  fistulous  communication  with  the  vagina.  We  thus  see  how  numerous 
and  strange  are  the  sources  of  pus  in  the  vagina,  and  that  a  purulent 
discharge  is  no  sure  evidence  of  disease  of  the  uterus  or  vagina.  Ex- 
ploration must  extend  beyond  these  organs. 

Many  discharges,  which  to  the  naked  eye  cannot  be  distinguished 
from  pus,  are  really  mucous.  The  microscope  discriminates  them  easily. 
The  distinction  is  important,  because  it  is  generally  true  that  the  un- 
broken mucous  membrane  of  the  genital  tract  does  not  yield  pus.  When 
true  pus  appears,  it  is,  therefore,  mostly  an  indication  of  erosion,  ulcer- 
ation, or  abscess.  As  Virchow  has  pointed  out,  all  mucous  membranes 
with  cylinder-epithelium  are  little  disposed  to  form  pus.  The  matter 
which  is  produced  is  found,  on  accurate  examination,  to  be  only  epi- 
thelium, though  it  may,  to  the  naked  eye,  have  a  thoroughly  purulent 
appearance.  The  intestinal  mucous  membrane  rarely  produces  pus 
without  ulceration.  The  mucous  membrane  of  the  uterine  tubes,  which 
is  often  covered  with  a  thick  mass  of  entirely  puriform  appearance, 
shows  almost  always  only  epithelial  elements. 

On  other  mucous  membranes — the  urethra,  for  example — we  observe 
copious  discharges  of  pus  without  the  least  ulceration. 


88  HEMORRHAGES. 


CHAPTER  XI. 

THE  SIGNIFICANCE  OF  HEMORRHAGIC  DISCHARGES. 

Discharges  of  blood  from  mucous  membranes  are  not  necessarily 
significant  of  local  disease.  For  example,  epistaxis  from  the  Schnei- 
derian  membrane  is  not  infrequent  in  childhood  and  old  age,  uncon- 
nected with  organic  disease  anywhere.  Although  when  it  has  once  set 
in,  the  bleeding  is  apt  to  go  on  to  an  excessive,  to  an  alarming,  and 
sometimes  even  to  a  fatal  extent ;  it  seems  in  the  first  instance  to  be 
determined,  by  an  eifort  of  the  vascular  system,  to  unburden  itself  of 
a  superfluous  accumulation.  It  appears  to  be  critical,  and  in  many 
cases  to  be  beneficial.  During  the  period  of  sexual  life  the  uterine 
mucous  membrane  is  the  outlet  towards  which  any  overflow  is  directed; 
during  this  period  Schneiderian  epistaxis  or  other  forms  of  hemorrhage 
are  rare ;  the  seat  of  election  for  critical  and  other  hemorrhages  is  the 
uterus.  And  it  is  remarkable  that,  as  a  result  probably  of  the  dispo- 
sition which  the  uterus  had  acquired  of  acting  as  a  periodical  evacuant 
long  after  the  cessation  of  menstruation  proper,  it  still  continues  to  be 
the  safety-valve  by  which  vascular  repletion  is  relieved. 

The  aptitude  of  the  uterus  to  serve  in  this  way  is  occasionally  mani- 
fested also  at  an  early  age ;  that  is,  just  before  or  about  the  institution 
of  the  menstrual  function.  Young  girls  sometimes  begin  with  a  copious 
flooding,  which  does  not  appear  to  be  distinctly  determined  by  ovulation. 

In  the  cases  referred  to,  hemorrhage  even  copious  does  not  imply 
disease,  at  least  not  disease  of  the  ovaries  or  uterus,  any  more  than  does 
bleeding  from  the  nose  imply  disease  of  the  Schneiderian  membrane. 
It  is  an  expression  of  constitutional  or  general  vascular  tension.  Still 
hemorrhage  from  the  uterus,  especially  if  prolonged  or  repeated,  is  so 
commonly  a  consequence  of  disease  of  that  organ,  that  it  ought,  as  a 
general  rule,  to  be  taken  as  a  warning  to  make  local  examination.  This 
is  the  more  imperative,  because  in  many  cases  this  examination  leads 
at  once  to  the  detection  of  a  cause  which  can  be  quickly  removed ;  and 
in  almost  all  cases  the  surest  way  of  stopping  dangerous  hemorrhage 
is  by  topical  applications. 

This  tendency  of  the  vascular  system  to  seek  its  outlet  by  the  uterus 
is  fortunate.  If  a  vent  were  not  found  here,  the  risk  of  internal 
eifusions  would  be  enormously  increased.  And  not  even  excepting  the 
Schneiderian  membrane,  the  uterine  mucous  membrane  is  the  most 
under  control. 

Climacteric  uterine  hemorrhage  may  avert  an  attack  of  apoplexy. 
The  outlet  of  blood  from  the  uterus  may  avert  effiision  from  the  ovary 
or  its  plexuses  into  the  peritoneum.  In  this  way  nature  often  proves 
herself  a  better  physician  than  the  modern  practitioner  who  has  aban- 
doned the  use  of  the  lancet. 


HEMORRHAGES.  89 

It  may  be  stated,  as  a  general  proposition,  that  whatever  produces 
hypersemia  predisposes  to  hemorrhage.  Thus  inflammation  takes  high 
rank  as  a  cause  of  hemorrhage.  Inflammation  involves  a  vis  a  fronte, 
attracting  blood  to  a  part,  and  so  filling  the  capillaries  that  they  juay 
burst. 

As  in  other  parts  of  the  body,  hemorrhage  from  the  uterus  may  be 
active  or  'passive.  In  active  hemorrhage  rupture  of  vessels  arises  from 
the  attraction  of  an  inordinate  quantity  of  blood  into  them.  In  pas- 
sive hemorrhage  the  escape  arises  not  simply  from  distension  from 
excess  of  blood,  but  generally  also  from  the  depraved  quality  of  the 
blood,  from  the  ill-nourished,  weakened  condition  of  the  coats  of  the 
vessels,  and  the  impeded  return  of  the  venous  blood.  In  a  woman 
who  had  suffered  much  from  metrorrhagia,  the  blood  contained  only 
2  parts  in  1000  of  globules,  1.8  of  fibrin,  61  of  solid  materials  of 
serum,  and  915  of  water. 

Hemorrhage  from  the  uterus  is  sometimes  called  menorrhagia,  some- 
times metrorrhagia,  sometimes  flooding. 

The  term  menorrhagia  implies  an  excessive  flow  of  the  menstrual 
discharge.  Although  in  fact  the  menstrual  nisus  or  ovulation  exerts  a 
powerful  initiative  and  aggravating  influence  in  the  production  of 
hemorrhage,  yet  there  often  exists  in  association  with  apparent  menor- 
rhagia some  local  disease  which  is  more  strictly  the  cause.  That  is, 
without  this  local  disease  the  ovarian  stimulus  would  produce  no  more 
than  the  ordinary  menstrual  flow.  But  a  mucous  membrane  once  set 
bleeding  easily  goes  on  pouring  off  blood.  It  may  be  likened,  and 
indeed  often  is  so  by  patients,  to  the  turning  on  of  a  tap.  The  vessels 
of  the  mucous  membrane,  whether  they  have  burst  or  not,  pour  off 
blood  with  the  greatest  readiness ;  and  the  stream  being  once  directed 
to  a  given  part  which  affords  ready  outlet,  a  derivative  action  towards 
this  part  is  easily  kept  up. 

Metrorrhagia  means  very  much  the  same  thing  as  flooding.  It  is 
used  to  express  a  copious  flow  of  blood  not  obviously  associated  with 
menstruation.  Uterine  hemorrhage  is  another  synonym.  As  a  gene- 
ral term  it  is  free  from  the  objection  which  applies  to  "  menorrhagia,'' 
as  it  expresses  simply  a  fact  independently  of  all  theory  of  causation. 

In  almost  every  case  of  uterine  disease  leading  to  hemorrhage,  peri- 
odicity more  or  less  regular  is  observed.  There  are  commonly  intervals 
of  remission  or  cessation.  Women  observe  that  their  courses  last  for 
two  or  three  weeks  at  a  time,  leaving  only  one  or  two  weeks  of  freedom. 
This  periodicity  is  often  preserved  long  after  the  natural  menopause, 
when  any  disease,  as  cancer  or  tumor,  continues  to  be  the  cause  of  hemor- 
rhage. In  the  same  way  as  patients  of  tuberculous  diathesis  are  eager 
to  persuade  themselves  that  occasional  haemoptysis  is  due  to  accidental 
insignificant  causes,  so  women  in  whom  losses  of  blood,  more  or  less 
periodical,  continue  or  recur  long  after  the  menopause,  are  ready  to 
believe  that  these  losses  are  natural  or  exaggerated  menstrual  discharges, 
and  that  they  may  be  taken  as  evidence  of  protracted  sexual  life. 

To  determine  what  losses  must  be  ascribed  to  natural  menstruation 
and  what  to  pathological  causes,  we  must  seek  to  define  the  characters 
of  natural  menstruation.     Any  marked  departure  from  these  characters 


90  HEMORRHAGES. 

inust  then  be  made  the  subjects  of  closer  investigation,  in  order  to  separate 
or  analyze  the  often  combined  physiological  and  pathological  factors. 

The  history  of  menstruation  will  be  studied  more  methodically 
hereafter.  It  will  be  enough  to  state  the  leading  features  of  healthy 
uncomplicated  menstruation.  Fluid  blood,  somewhat  glutinous,  is 
discharged  gradually,  to  the  amount  of  two  to  four  or  six  ounces,  over 
a  period  of  two,  three,  or  four  days,  at  regular  intervals  of  twenty- 
eight  days,  or  nearly  so,  beginning  at  the  age  of  twelve,  thirteen,  or 
fourteen,  and  lasting  until  forty-five  or  forty-eight. 

There  is  a  range  of  variation  in  all  these  characters,  depending  in 
some  cases  upon  individual  peculiarities.  For  this  allowance  must  be 
made.  But  it  is  a  safe  and  prudent  clinical  rule  to  suspect  that  any 
wide  departure  from  these  characters  depends  upon  some  pathological 
complication.  Taking  the  characters  of  normal  menstruation  as  our 
standard,  we  shall  be  justified  in  concluding  that  discharges  of  coagu- 
lated blood,  discharges  habitually  exceeding  four  or  six  ounces,  dis- 
charges continued  for  a  week  or  more,  leaving  intervals  of  freedom 
shortened  to  three  weeks  or  less,  discharges  occurring  during  the 
proper  intervals  between  the  periods,  and  discharges  occurring  long 
after  the  age  of  forty-five  or  forty-eight,  especially  if  excessive  or 
irregular  as  to  periodicity,  are  of  pathological  significance.  The  same 
thing  may  be  said  of  hemorrhagic  discharges  recurring  in  women  after 
the  menopause ;  that  is,  after  a  complete  cessation  of  the  ordinary 
menstrual  flow  for  a  year  or  more.  It  may  be  assumed,  as  a  physi- 
ological fact,  that  the  function  of  ovulation  is  not  resumed  after  having 
been  suspended  at  its  natural  term.  The  ovary  then  has  undergone  a 
process  of  involution  or  atrophy  which  is  incompatible  with  the  de- 
velopment of  ova.  Discharges  of  blood,  then,  after  the  menopause 
depend  upon  other  causes  than  normal  ovarian  stimulus.  The  circum- 
stances under  which  hemorrhage  appears  will  occasionally  declare  its 
character.  For  example,  hemorrhage  may  immediately  follow  some 
accident,  as  sudden  exertion,  or  coitus. 

In  addition  to  the  general  or  average  standard  deduced  from  the  study 
of  the  natural  history  of  menstruation,  Ave  shall  often  draw  the  most 
trustworthy  conclusions  from  the  particular  study  of  the  individual  pa- 
tient. She  herself  must  often  furnish  her  own  standard  of  comparison. 
Any  marked  change  from  the  habitual  characters  of  the  menstrual  func- 
tion will  point  to  the  necessity  of  inquiring  into  the  cause. 

All  hemorrhages  may  be  considered  abnormal  which  are  irregular 
in  their  appearance,  or  excessive  in  duration  or  quantity,  or  which  ob- 
viously tell  upon  the  system  by  inducing  anaemia  or  debility.  An- 
other test  of  abnormality  will  often  be  found  in  the  association  of  other 
symptoms  with  the  hemorrhage. 

Abnormal  hemorrhage  is  not  always  marked  by  excessive  quantity. 
Blood  may  appear  in  streaks  or  small  quantities  mixed  with  the  mucus 
of  leucorrhcea.  This  will  often  be  connected  with  breach  of  surface  of 
the  mucous  membrane,  as  abrasion  or  ulceration ;  often,  however,  with 
simple  congestion  or  inflammation.  Apart  from  pregnancy,  a  copious 
flow  of  blood  will  generally  depend  upon  some  organic  alteration  in 


HEMORRHAGES.  91 

the  structure  of  the  uterus,  as  hypertrophy  of  the  body  or  cervix,  the 
growth  of  tumors  or  polypi,  or  malignant  disease. 

If  copious  hemorrhages  occur  in  a  woman  past  the  childbearing  age, 
the  probability  is  great  that  the  cause  is  malignant  disease ;  and  this 
probal)ility  rises  if  the  cessation  or  diminution  of  the  blood-flow  is  fol- 
lowed by  a  watery  discharge  stained  with  blood,  offensive  in  odor,  and 
showing  debris  of  tissue  in  the  form  of  shreds.  It  must  be  remembered, 
however,  that  the  discharges  attendant  upon  polypus  and  inversion  of 
the  uterus  may  present  very  similar  characters.  Many  cases  of  poly- 
pus have  been  seen  in  which  the  history,  subjective  symptoms,  and  dis- 
charges so  nearly  resembled  those  of  malignant  disease  that  the  prob- 
ability in  favor  of  cancer  seemed  great  until  examination  was  made. 

Abortion  or  labor  at  term  is  not  seldom  followed  by  hemorrhages 
more  or  less  continuous  or  intermittent  for  many  weeks  or  even  months ; 
so  long,  indeed,  that  their  dependence  upon  the  puerperal  changes  may 
be  lost  sight  of. 

Uterine  hemorrhages  may  be  classified  as  follows : 

A.  Hemorrhages  escaping  externally,  without  alteration  of  the  struc- 
ture of  the  uterus,  as — 

1.  From  primordial  disease  of  the  heart,  liver,  or  lungs. 

2.  Exaggerations  of  the  menstrual  function,  as  in  plethoric  girls  at 

the  onset  of  menstrual  life,  and  in  women  at  the  menopause. 

3.  Throughout  menstrual  life,  or  beginning  towards  its  close,  from 

abdominal  or  hepatic  congestion  or  obstruction.     In  some,  hem- 
orrhagic menstruation  seems  hereditary. 

4.  From  emotion  or  physical  shock. 

5.  Complementary  of  hemorrhages  suppressed  elsewhere. 

6.  From  sudden  suppression  of  the  action  of  the  skin. 

7.  From  ovarian  or  mammary  excitation.     Excess  of  coitus,  espe- 

cially if  at  menstrual  epoch. 

8.  The  climacteric  and  senile  hemorrhage. 

9.  From  blood  disease ;  as  variola,  scarlatina,  tyj)hoid,  acute  atrophy 

of  the  liver,  leucocythemia,  scurvy. 

In  this  class  we  see  that  the  cause  of  hemorrhage  may  be  distant 
from  the  uterus.  Hypertrophy  of  the  heart  is  a  not  uncommon  cause 
of  uterine  hemorrhage,  especially  in  pregnancy  and  childbed.  The 
hypertrophy  may  be  the  result  of  antecedent  disease,  or  of  pregnancy. 
This  is  one  cause  why  the  risk  of  hemorrhage  increases  with  the  num- 
ber of  pregnancies.  There  is  an  increasing  difficulty  in  the  process  of 
involution  of  the  heart,  and  an  increasing  disposition  to  fall  into  fatty 
degeneration.  A  feeble,  fatty  heart  also,  I  have  observed,  disposes  to 
uterine  hemorrhage. 

Liver  disease  may  act  simply  or  as  complicating  heart  disease.  It 
acts  especially  in  women  past  forty,  during  the  climacteric,  and  in  those 
who  indulge  in  drink. 

Lung  diseases,  especially  those  marked  by  dyspnoea  and  hypersemia 
or  oedema,  dispose  to  uterine  congestion  and  hemorrhage. 

Uterine  hemorrhage  is  sometimes  observed  in  phthisis,  although  more 
commonly  this  disease  induces  amenorrhoea. 

It  is  not  always  safe  or  judicious  to  stop  hemorrhage  depending  upon 


92  HEMORRHAGES. 

remote  obstructions  to  the  circulation  hastily  or  completely.     There  can 
be  no  doubt  that  they  act  as  useful  evacuants  and  derivatives. 

Menorrhagia  has  occasionally  proved  fatal  at  the  onset  of  the  men- 
strual function  in  girls.  The  late  Mr.  Obr6  related  the  case  of  a  vir- 
gin, aged  fourteen  years  and  three  months,  in  whom  the  first  menstru- 
ation set  in  violently,  and  could  not  be  checked.  Everything  was  found 
healthy,  except  the  uterine  mucous  membrane,  which  was  softened  and 
ecchymosed,  and  in  some  places  detached  from  the  muscular  coat.  This 
alteration  was  probably  nothing  more  than  the  menstrual  decidua  in- 
filtrated M'ith  blood. 

B.  The  hemorrhages  of  pregnancy — 

1.  Abortion. 

2.  Detachment  of  placenta. 

3.  Extra-uterine  gestation. 

4.  Retained  placenta  or  clots, — placental  or  fibrinous  polypus. 

5.  Hydatidiform  placenta. 

6.  Varix  of  the  vulva  or  vagina. 

It  must  be  borne  in  mind  that  in  many  cases  of  hemorrhage  in  preg- 
nant women  the  blood  does  not  come  from  the  cavity  of  the  uterus,  but 
from  the  cervix  uteri,  which  may  be  abraded  and  hypertrophied.  The 
intense  hypersemia  of  pregnancy  easily  issues  in  hemorrhage  when  the 
mucous  surface  is  unsound. 

Many  of  the  conditions,  with  or  without  alteration  of  structure, 
which  occur  in  non-pregnant  women,  may  occur  also  in  the  j)regnant; 
and  pregnancy  may  even  increase  the  disposition  to  hemorrhage. 

C.  Hemorrhages  with  alteration  of  structure — 

1.  Metritis  proper. 

2.  Inflammation  of  the  cervix  uteri. 

3.  Engorgement  of  the  body  and  cervix  induced  by  stenosis  or 

displacement  or  distortion  of  the  uterus  or  other  causes. 

4.  Hypertrophy  of  the  cervix  or  of  the  body  of  the  uterus,  espe- 

cially of  the  mucous  membrane,  as  from  syphilis. 

5.  Fungous  granulations  of  the  os,  abrasions,  ulcerations,  especially 

if  there  is  syphilitic  complication. 

6.  Fibroid  tumors. 

7.  Polypi  of  the  uterine  cavity,  cervix,  or  os,  or  of  the  vagina. 

8.  Cancer  or  sarcoma  in  the  non-ulcerated  state,  and  in  the  ulcer- 

ated state. 

9.  Wounds   of  the  uterus,  vagina,  or  vulva  from   accident,  opera- 

tions, leech-bites,  abrasion  or   irritation,  as  from  ill-selected 
pessaries. 

10.  Voiding  the  blood  of  thrombi  or  of  retro-uterine  hsematoceles. 

11.  Varicosity  of  the  vessels  of  the  labia,  which  may  burst. 

12.  Imperfect  involution  of  the  uterus  and  obstruction  of  circulation 

kept  up  by  impeded  mobility  from  peri-uterine  eflusions. 

13.  Hyjiersemia  induced  by  the  uterus  being  within  the  range  of 

any  abnormal  vascular  activity,  as  an  extra-uterine  gesta- 
tion cyst. 
Hematuria,  or  disease  of  the  meatus   urinarius,    may  possibly  be 
mistaken  for  hemorrhage  of  uterine  origin. 


HEMOREHAGES.  93 

D.  Hemorrhages  poured  out  internally — 

1.  Retri-uterine    hsematocele,    from    blood    from    ovary,    ovarian 

plexuses,  or  Fallopian  tubes,  under  menstrual  nisus. 

2.  Peri-uterine  lijematocele  or  thrombus,  or  effusion  into  the  con- 

nections of  the  broad  ligaments,  or  between  the  bladder  and 
cervix  uteri. 
Similar  events  may  happen  from  abnormal  ovarian  congestions ;  from 
rupture  of  ovarian  tumors,  or  of  vessels  in  their  walls;  from  rupture 
of  varices  of  the  ovary  or  broad  ligaments. 

Under  ovarian  menstrual  stimulus  blood  may  be  poured  out  into 
the  abdominal  cavity  because  there  is  some  obstruction  in  the  course 
of  the  genital  canal. 

1.  The  Fallopian  tubes  may  be  occluded;  there  may  be  stenosis 

or  atresia  of  the  uterus,  vagina,  or  vulva;  there  may  be  re- 
troflexion of  the  uterus. 
In  these  cases  blood    may  accumulate  above  the  seat  of  the  ob- 
struction, and  regurgitate  into  the  abdomen. 

2.  There  may  also  be  retrograde  hemorrhage  from  abortion. 

3.  Abdominal  hemorrhage  may  arise  from  rupture  of  the  sac  of  an 

extm-uterine   gestation.     External    hemorrhage    commonly 
precedes  or  attends  the  rupture  and  the  internal  effusion. 

4.  The  gravid  uterus   may  rupture,  with  or  ^¥ithout  violence,  after 

the  fourth    month.     This    is    more    likely  to  happen  when 
the    gestation    is    mural,  or    in  one  horn  of  a  two-horned 
uterus.     In  these  cases  there  will  probably  be  some  external 
hemorrhage  also. 
A    methodical  analysis  of  the  various    causes  of  uterine    hemor- 
rhage for  diagnostic  purposes  would  carry  us  through  almost  the  en- 
tire field  of  ovarian   and  uterine  pathology.     The  morbid  conditions 
which  are  attended  by  hemorrhage  will  be  described  in  their  proper 
places.     We  can  only  now  enumerate  the  conditions,  physiological  or 
pathological,  which  are  associated  with  hemorrhage;  and  seek  to  lay 
down  compendious  principles  of  diagnosis  and  treatment. 

In  practice  we  are  continually  called  upon  to  treat  symptoms  or 
consequences  of  disease.  It  is  the  merest  folly,  or  affectation  of  science 
in  many  cases,  to  pretend  to  remove  a  disease  by  at  once  attacking 
the  presumed  cause.  The  folly  is  as  great  to  postpone  treatment 
until  we  have  discovered  the  cause.  In  no  case  is  this  pretension 
more  absurd  or  more  dangerous  than  in  that  of  hemorrhage  from  a 
mucous  membrane.  Whilst  we  are  waiting  to  discover  the  cause,  the 
patient  may  bleed  to  death.  If  we  apply  ourselves  at  once  to  stop  the 
hemorrhage,  we  may  save  her. 

Treatment. — The  first  practical  rule  to  observe  when  in  presence  of 
a  profuse  flooding  is  to  take  off"  the  pressure  of  gravitation,  by  placing 
the  patient  in  a  horizontal  posture  with  the  pelvis  somewhat  ele- 
vated; to  remove  all  articles  of  dress  which,  by  their  pressure  upon 
the  chest  or  waist,  impede  the  circulation ;  to  remove,  as  far  as  pos- 
sible, all  sources  of  excitement  or  emotion ;  above  all,  to  obtain  abso- 
lute rest.  Wounds  or  injuries  which  would  be  of  no  consequence  if  the 
patient  remained  perfectly  quiet  and  recumbent,  may,  so  rich  is  the 


94  HEMOREHAGES. 

vascularity  and  so  free  the  intercommunication  of  the  vessels  of  the 
pelvis,  lead  to  fatal  hemorrhage,  if  she  assume  the  erect  posture,  or 
undertake  any  bodily  exertion. 

The  next  practical  rule  is  to  endeavor  to  stop  the  bleeding  as  quickly 
as  possible,  without  waiting  to  inquire  into  its  cause.  This  can  rarely 
be  done  effectually  or  certainly  without  the  application  of  topical  reme- 
dies. This  necessarily  implies  a  preliminary  examination  by  the  finger, 
hand,  or  speculum.  We  thus  obtain  incidentally  useful,  often  adequate, 
diagnostic  information.  For  example,  we  may  find  a  polypoid  tumor 
or  a  wound.  The  hemorrhage  may  then  be  stopped  by  removing  the 
cause.  We  may  find  malignant  disease ;  and  then  all  we  can  do  is  to 
stop  the  bleeding  by  the  application  of  powerful  astringents  or  cau- 
teries, as  the  perchloride  of  iron  or  chromic  acid.  We  may  find  a 
fibroid  of  the  uterus ;  and  the  hemorrhage  may  be  controlled  by  the 
same  remedies,  postponing  treatment  adapted  to  prevent  the  recurrence 
of  bleeding  to  a  more  favorable  opportunity. 

We  may  find  an  ovum  presenting  at  the  os  uteri,  or  some  other  form 
of  heuiorrhage  connected  with  pregnancy.  The  treatment  of  these 
forms  cannot  be  discussed  in  this  work.  I  have  described  it  carefully 
in  my  "  Lectures  on  Obstetric  Operations." 

Where  we  find  no  cause  that  admits  of  immediate  removal,  we  may 
still  arrest  the  hemorrhage.  The  method  which  is  commonly  the  readi- 
est, because  it  requires  no  special  appliances,  is  plugging  the  vagina. 
Whilst  waiting  for  these  special  appliances,  it  may  be  desirable  to  plug. 
This  is  done  by  pushing  pieces  of  lint,  linen,  sponge,  or  silk  handker- 
chiefs into  the  vagina.  First  of  all,  it  is  desirable  to  remove  clots  by 
the  hand,  and  to  wash  out  the  vagina  with  cold  water.  Then  holding 
the  labia  apart  with  the  expanded  fingers  of  one  hand,  the  plugging 
materials,  lubricated  in  oil,  or  better,  Avith  oil  containing  an  eighth  or 
tenth  part  of  carbolic  acid,  or  lard,  are  pushed  in  gradually  by  the  fin- 
gers of  the  other  hand,  or  by  aid  of  the  uterine  sound,  the  handle  of  a 
tooth-brush,  or  any  other  accessible  instrument.  The  plugging  must 
be  firm,  packing  the  vagina  pretty  tightly.  It  is,  however,  generally 
preferable  to  plug  by  the  aid  of  a  speculum.  The  pieces  ai^e  thus  ac- 
curately packed,  and  the  speculum  is  gradually  withdrawn.  In  this 
way  uterine  and  vaginal  hemorrhage  may  frequently  be  checked  for  a 
while,  and  time  be  gained  for  choice  of  more  scientific  remedies.  But 
plugging  is  not  free  from  objections.  In  the  first  place,  if  the  case  be 
one  of  malignant  disease,  tight  packing  of  the  vagina  is  apt  to  break 
down  the  fragile  malignant  tissue,  to  increase  the  bleeding,  and  favor 
ulceration.  In  the  next  place,  after  a  while  the  elastic  and  contractile 
vagina  compresses  the  plug,  saturated  with  blood,  into  a  compact  ball 
or  cylinder,  which  no  longer  fits  its  calibre ;  blood  then  easily  flows 
past ;  or  being  retained  concealed,  may  give  rise  to  a  false  security,  and 
lead  us  to  defer  more  effectual  remedies.  In  the  third  place,  plugs,  by 
heating  and  distending  the  parts,  are  a  source  of  irritation  and  distress; 
they  often  in  this  way  seem  even  to  keep  up  hemorrhage.  In  the  fourth 
place,  if  retained  a  few  hours,  the  plugs,  or  the  retained  blood,  decom- 
pose and  become  exceedingly  foul.  Fifthly,  the  compression  of  the  ure- 
thra, or  the  metastatic  irritation,  often  causes  retention  of  urine.     And 


HEMORRHAGES.  95 

even  if  the  plug  have  arrested  the  hemorrhage,  this  often  breaks  out 
again  when  the  phig  is  removed. 

In  the  majority  of  cases,  therefore,  it  is  wise  to  look  upon  plugging 
as  a  mere  temporary  expedient,  to  be  adopted  whilst  preparing  for  more 
trustworthy  means. 

I  could  give  no  rule  of  more  general  application  or  more  valuable 
than  this  :  In  all  cases  of  hemorrhage  coming  from  the  body  of  the  uterus 
obtain  and  maintain  free  patency  of  the  cervical  canal. 

In  cases  of  abortion,  of  the  hemorrhages  of  gestation,  of  intra-uterine 
polypi,  or  fibroids,  of  hypertrophy  of  the  mucous  membrane,  of  malig- 
nant disease  of  the  interior  of  the  uterus,  to  obtain  free  external  escape 
for  the  hemorrhage  and  free  access  to  the  source,  in  order  to  control  the 
bleeding,  is  the  first  necessity.  We  might,  it  is  true,  in  almost  every 
case  introduce  a  catheter  or  tube  to  carry  a  styptic  injection  into  the 
uterus.  But  this  proceeding,  invaluable  if  properly  carried  out,  may 
be  useless  or  even  dangerous  if  resorted  to  whilst  the  cervix  uteri  is 
contracted.  Blood  retained  in  the  cavity  of  the  uterus  forms  clots 
which,  under  the  spasmodic  contractions  they  excite,  become  compressed 
into  firm  masses  of  fibrin  by  the  squeezing  out  of  the  serum.  These 
coagula  cannot  make  their  way  through  the  constricted  cervical  canal ; 
they  may  even  become  closely  adherent  to  the  walls  of  the  uterus,  form- 
ing the  "fibrinous  polypi."  Their  presence  in  any  form  is  a  source  of 
irritation  and  suffering  :  by  causing  alternate  contraction  and  dilatation 
of  the  uterus  they  keep  uj)  hemorrhage ;  and  occupying  the  uterus,  in- 
jections thrown  into  the  cavity  are  lost  upon  the  clots  instead  of  con- 
stringing  the  bleeding  surface.  Moreover,  as  I  shall  show  hereafter, 
wherever  there  has  long  existed  a  narrowing  of  the  cervical  canal,  there 
will  be  produced  a  dilatation  of  the  genital  tract  above  the  stenosis. 
Hence,  there  will  be  serious  danger  of  injected  fluids  being  driven  along 
the  dilated  Fallopian  tubes  into  the  abdominal  cavity.  As  a  conse- 
quence of  the  same  condition,  there  is  also  serious  danger  of  the  blood 
which  gathers  in  the  uterine  cavity  and  tubes  being  driven  in  a  retro- 
grade course  into  the  peritoneum.  This  is  one  way  in  which  retro- 
uterine hematocele  is  produced.  It  is  the  way  which  may  most  suc- 
cessfully be  guarded  by  securing  a  free  outlet  by  the  vagina. 

In  the  case  of  retained  ova,  membranes,  or  placenta,  or  clots,  the  first 
indication  is  usually  to  remove  these.  To  do  this  it  is  often  necessary 
to  pass  in  one  or  two  fingers  to  break  them  up  and  to  bring  them  away. 
In  the  case  of  intra-uterine  polypi,  there  must  be  room  to  introduce  an 
instrument,  as  well  as  a  guiding  finger.  In  the  case  of  an  unhealthy 
condition  of  the  uterine  mucous  membrane,  free  passage  is  Avanted  for 
the  application  of  haemostatics.  These  are,  I  believe,  most  useful  if  ap- 
plied in  a  tolerably  concentrated  form.  To  do  this,  it  is  preferable  to 
introduce  them  soaked  in  swabs  mounted  on  sticks  or  whalebone  rods. 
If  a  swab  cannot  be  introduced,  and  it  is  difficult  to  do  it  unless  the 
cervix  be  very  widely  open,  because  the  charged  swab  as  it  touches  the 
cervix  in  its  passage  contracts  the  canal,  it  is  then  necessary  to  resort 
to  injection,  or  the  introduction  of  styptics  in  the  solid  form. 

If  any  further  reason  were  wanted  to  recommend  the  preliminary 
dilatation  of  the  cervix  uteri,  it  would  be  this :  It  is  in  many  cases 


96  HEMOEEHAGES. 

enough  to  arrest  the  bleeding.  And,  if  not  of  itself  successful,  it  at  any 
rate  opens  the  road  by  which  we  can  pursue  a  treatment  that  will  succeed. 

What  are  the  means  of  dilating  the  cervix  f — These  are  various,  and 
the  choice  will  'depend  upon  the  nature  of  the  case.  If  it  be  one  of 
abortion,  of  intra-uterine  polypus  or  tumor,  or  of  morbid  condition  of 
the  mucous  membrane,  it  will  generally  be  easy  to  place  one  or  more 
laminaria-tents  or  sponge-tents,  which  in  the  course  of  a  few  hours  will 
etFect  the  desired  dilatation,  and,  Avhilst  acting,  will  generally  check 
the  bleeding.  If  the  case  be  metrorrhagia  from  fibroid  tumor,  or 
menstruation  obstructed  by  stenosis  of  the  os  externum  uteri,  it  may  be 
necessary  to  dilate  the  part  by  incision.  This  operation  wdll  frequently 
not  only  prepare  the  way  for  relief  from  the  immediate  danger,  but  it 
is  an  essential  condition  of  prevention  in  the  future. 

When  we  have  stopped  or  moderated  the  bleeding,  our  next  inquiry 
will  be,  how  we  are  to  prevent  its  recurrence  ?  This  will  lead  to  the 
study  of  the  causes,  immediate  and  remote,  of  the  hemorrhage,  and  of 
the  means  of  alleviating  or  removing  those  causes.  I  cannot  in  this 
place  further  anticipate  the  history  of  the  conditions  associated  w^ith 
hemorrhage.  They  will  be  systematically  discussed  under  their  ap- 
propriate heads. 

Active  hemorrhage  is  characterized  by  symptoms  of  fluxion  or  rapid 
determination  of  blood  to  the  pelvic  organs,  by  heat,  throbbing,  per- 
haps pruritus,  pain,  sense  of  fulness  at  night,  and  bearing  down  of  the 
uterus.  If  examination  be  made  by  touch  the  vagina  is  felt  hot;  per- 
haps the  vaginal  pulse  is  perceived  ;  there  is  increased  softness  of  the 
vaginal  portion  ;  and  tenderness  of  the  uterus,  when  pressure  is  made 
upon  its  walls  through  the  vaginal  roof.  The  general  system  evinces  the 
perturbation  caused  by  the  local  molimen.  There  is  a  state  of  febrility, 
of  vertigo,  of  swimming  of  the  eyes,  the  eyes  are  suffused,  and  nervous 
symptoms  of  an  hysterical  kind  are  frequent. 

Passive  hemorrhage  is  not  marked  by  the  signs  of  fluxion  or  active 
determination.  There  is  not  the  same  local  hypersemia  as  in  the  active 
form  ;  and  it  is  not  preceded  by  the  same  heat,  vascular  tension,  or  at- 
tended by  the  vaginal  pulsation.  Having  once  occurred,  passive  hemor- 
rhage tends  to  establish  itself  by  degrading  the  quality  of  the  blood, 
and  by  altering  the  tissues,  impairing  their  tonicity,  and  rendering 
them  more  easily  permeable.  The  blood  discharged  often  becomes 
more  serous  in  character. 

We  may  try  to  turn  aside  the  fluxion  from  the  uterus  by  the  appli- 
cation of  cold.  This  is  best  done  by  introducting  ice  into  the  vagina. 
It  is  usual  to  apply  cold  wet  cloths  to  the  vulva  and  abdomen.  This 
may  sometimes  be  serviceable,  but  it  is  often  the  reverse.  The  patient 
gets  soaked  in  water  ;  and  the  resulting  chill  may  favor  the  develop- 
ment of  subsequent  j^eritonitis  or  bronchitis. 

In  the  passive  hemorrhages  it  is  of  great  importance  to  secure  free 
evacuation  of  the  bowels.  Passive  hemorrhages  are  most  frequent  in 
women  W'ho  have  reached  or  passed  middle  age.  It  is  then  that  he- 
patic congestion  and  inaction  of  the  intestines  are  most  common. 
And  any  loading  of  the  colon  or  rectum  is  always  a  serious  aggrava- 
tion in  cases  of  pelvic  hypersemia. 


HEMORRHAGES.  97 

Marked  advantage  is  sometimes  obtained  from  the  use  of  remedies 
which  promote  contraction  of  the  uterine  muscular  fibre  ;  or  which  in 
some  other  way  possess  haemostatic  properties.  Amongst  these  the  most 
trustworthy  are  ergot  of  rye,  digitalis,  cinchona,  turpentine,  ipecac- 
uanha, acetate  of  lead,  tannin,  alum,  dilute  sulphuric  acid. 

After-treatment. — Hemorrhage,  especially  the  active  form,  is  followed 
by  a  stage  of  reaction,  of  erethism,  which  has  been,  not  inaptly,  called 
hemorrhagic  fever.  The  pulse  is  quickened,  the  skin  is  warm  and  dry, 
there  is  intense  beating  headache,  restlessness,  hyperesthesia  manifested 
in  general  irritability,  and  morbid  sensitiveness  to  light  and  sound.  In 
this  condition  it  is  a  serious  clinical  error  to  administer  iron.  It  may 
be  theoretically  true  that  the  vascular  system  wants  iron ;  but  the  effect 
of  giving  it  is  to  add  fuel  to  the  fever  and  excitement,  to  parch  the 
tongue  and  mucous  membranes  generally,  to  check  secretion,  to  increase 
headache  and  restlessness,  to  disturb  digestion  and  nutrition.  The 
system  may  want  iron,  but  it  wants  saline  solutions  more;  and  it  wants 
these  first.  Saline  solutions  serve  better  than  anything  else  to  rejjienish 
the  exhausted  circulating  fluid.  The  vessels  seem  to  crave  in  the  first 
instance  for  a  sufficient  volume  of  fluid  as  a  necessary  condition  for  the 
efficient  dynamic  action  of  the  circulating  apparatus.  It  is  a  fact  deter- 
mined by  the  observations  of  Dr.  Little  and  Mr.  L.  S.  Little  on  cholera 
patients,  that  the  injection  of  saline  solutions  of  about  the  specific  grav- 
ity of  the  blood  will  revive  persons  on  the  point  of  sinking.  I  can 
affirm,  from  large  experience,  that  the  exhibition  of  salines  after  hemor- 
rhages is  followed  by  the  best  effects.  They  exert  a  marked  influence 
in  subduing  vascular  excitement ;  they  allay  the  fever,  calm  nervous 
irritability,  improve  the  secretioVis,  and  prepare  the  way  for  iron  and 
other  tonics,  which  at  a  later  stage  find  useful  application.  The  best 
form  of  saline  is  the  acetate  of  ammonia,  freshly  prepared.  To  this 
may  usefully  be  added  a  sedative,  as  Battley's  solution,  and  sometimes 
digitalis.  At  a  later  stage  mineral  acids  and  bark,  in  decoction,  or  the 
liquor  cinchonse  may  be  given  ;  and  later  still  iron.  The  best  chalyb- 
eate preparations  are  the  citrate  of  iron,  given  in  an  effervescent  form, 
or  the  acetate  of  iron.  The  doses  at  first  should  be  small,  so  as  to  feel 
the  way.  Strict  rest  must  be  maintained,  so  as  to  economize  to  the 
utmost  the  feeble  powers  of  the  system ;  to  promote  this,  sedatives  to 
procure  sleep  are  often  of  signal  service.  If  opium  can  be  borne,  as  it 
often  is,  it  may  be  given  with  the  saline,  or  separately,  in  the  solid  form, 
as  the  compound  opium  pill,  in  5-grain  doses,  or  as  Dover's  powder, 
in  10-grain  doses.  If  it  is  not  borne,  we  have  a  precious  resource  in 
chloral,  which  may  be  given  in  scruple  doses. 

Alcohol,  in  the  form  of  wine  or  spirits,  will,  at  times,  act  as  an  efficient 
sedative,  as  well  as  a  stimulant.  But  stimulation,  or  "  keeping  the 
patient  up,"  is  often  overdone.  Stimulants  must  be  given  watchfully, 
and  with  discretion.  Taken  largely,  they  disturb  the  balance  of  the 
stomach,  provoke  vomiting,  excite  the  circulation  unduly,  and  may  even 
maintain  or  cause  a  return  of  the  hemorrhage. 

Light,  easily  assimilable  nourishment  should  be  given  in  small 
quantities,  at  short  intervals. 


98  PA  IX. 


CHAPTER  XII. 

THE  SIGNIFICANCE  OF  PAIN. 

It  may  be  stated,  as  a  general  law,  that  pain  referred  to  a  particular 
part  or  organ  is  presumptive  evidence  of  disorder,  structural  or  func- 
tional, of  that  part  or  organ.  Of  course,  in  some  cases,  the  disorder  is 
onlv  secondary  or  consequential  upon  disorder  in  some  other  part. 
Thus,  one  form  of  headache  is  the  consequence  of  disordered  stomach, 
and  is  cured  by  correcting  the  condition  of  the  digestive  organs.  Pain 
in  one  part  may  be  the  reflex  response  to  distress  in  another  part.  Of 
this  we  see  repeated  examples  in  the  history  of  ovarian  and  uterine 
disease.  Pain  in  the  dorsal,  lumbar,  and  sacral  parts  of  the  spine  is  a 
frequent  phenomenon  in  connection  with  uterine  disease.  It  is  often 
the  predominant  symptom.  The  spinal  pain  may  be  so  severe  and 
enduring  that  it  attracts  the  chief  attention ;  and,  unless  the  rule  of 
interrogating  all  the  functions  be  carefully  followed,  it  is  easy  to  fall 
into  the  snare  of  regarding  the  case  as  one  of  spinal  irritation,  vertebral 
disease,  or  simply  hysteria.  If  this  error  be  committed  the  patient 
will  probably  be  doomed  to  a  long  course  of  mechanical  or  medicinal 
treatment,  under  which  the  general  health  may  break  down,  the  original 
disease  pursuing  its  course  all  the  while. 

Attempts  well  deserving  consideration  have  been  made  by  observing 
the  seat  of  the  pains  complained  of,  and  interpreting  by  the  knowledge 
of  the  sources  and  distribution  of  the  nerves  supplying  the  pelvic 
organs,  to  diagnose,  with  something  like  precision,  the  nature  and  seat 
of  the  pelvic  disease. 

There  are  certain  facts  which  are  so  frequent  in  their  recurrence  and 
association  as  to  lend  weight  to  this  method  of  analysis.  But  like 
all  other  methods  of  clinical  research  conducted  upon  one  line,  it  is  ex- 
ceedingly apt  to  lead  astray.  It  is  useful  as  a  means,  but  not  as  the 
only  means.     We  want  help  from  every  quarter. 

Pain,  in  association  with  ovarian  and  uterine  disease,  is  referred,  first, 
to  the  region  of  the  ovary  or  uterus  itself;  secondly,  chiefly  to  the 
sacral,  or  lumbar,  or  lumbo-sacral  region ;  thirdly,  to  the  hips,  thighs, 
and  down  the  legs.  In  many  cases  pains  may  be  said  to  radiate  from 
the  pelvis  as  a  centre,  in  various  directions,  as  to  the  back,  abdomen, 
and  thighs. 

Pain  in  an  organ,  arising  during  or  aggravated  by  the  performance 
of  its  functions,  is  especially  presumptive  evidence  of  structural  disorder 
of  that  organ.  This  is  true  of  pain  during  menstruation,  and  of  pain 
in  the  performance  of  the  sexual  act.  This  part  of  the  subject  will  be 
discussed  more  particularly  under  the  heads  "  Dyspareunia "  and 
"  Dysmenorrhoea." 

Pain  described  as  in  one  or  other  inguinal  region  or  rather  deeper,  \s 


PAIN.  99 

often  referred  to  the  ovary,  and  is  taken  as  evidence  of  ovaritis,  or  of 
ovarian  irritation.  But  in  the  great  majority  of  instances  this  presumed 
ovarian  pain  is  the  signal  of  subacute  or  chronic  inflammation  of  the 
neck  of  the  uterus.  This  has  been  insisted  upon  by  Dr.  Henry  Bennet. 
I  find  this  pain  so  frequent  in  connection  with,  disease  of  the  neck  of 
the  uterus,  there  being  no  perceptible  concurrent  disease  of  the  ovary, 
that  I  hesitate  in  every  case  to  regard  it  as  due  to  ovarian  disease  until 
I  have  examined  by  touch  the  ovaries  themselves,  as  well  as  the  uterus.  , 
If  under  touch  we  make  out  that  the  ovaries  are  swollen,  and  exhibit 
increased  tenderness,  we  get  the  required  confirmation  as  to  the  impli- 
cation of  these  organs.  I  have  several  times  obtained  experimental 
proof  of  pain  in  the  ovary  being  due  to  uterine  disease.  Touching  the 
OS  uteri  has  caused  pain  referred  to  the  region  of  the  ovary. 

By  those  who  do  not  examine  at  all,  either  uterus  or  vagina,  except 
by  external  palpation,  this  ovarian  pain  is  often  called  "  ovarian  irrita- 
tion," or  "  ovaritis ;"  and  leeches,  blisters,  or  irritating  ointments  are 
resorted  to  to  subdue  it.  This  so-called  "  ovarian  irritation,"  however, 
does  not  deserve  to  be  ranked  as  a  morbid  entity  demanding  special 
treatment.  There  may,  indeed,  be  irritation  of  the  ovary ;  but  then 
there  must  be  something  to  irritate  it.  It  is  this  something  we  should 
search  for.  And  this  something,  in  the  majority  of  cases,  has  its  seat 
not  in  the  ovary  itself,  but  in  the  uterus.  The  pain  is  more  frequent 
in  the  left  ovary  than  in  the  right. 

Pain  referred  to  the  uterus  itself,  intensified  under  touch,  is  often 
attributed  to  "  irritable  uterus,"  and  this  vague  expression  is  sometimes 
accepted  as  a  satisfactory  diagnosis.  ISTow,  as  is  the  case  of  "  ovarian 
irritation,"  logic  and  clinical  observation  compel  to  the  conclusion  that 
since  the  uterus  shows  signs  of  being  irritated,  there  is  an  irritating 
cause,  which  it  is  our  business  to  find  out. 

Another  expression  which  is  often  adopted  as  a  conventional  substi- 
tute for  precise  diagnosis  is  "  neuralgia  of  the  uterus,"  or  "hysteralgia." 
These  terms  really  mean  nothing  more  than  "  pain  in  the  uterus."  To 
employ  Greek  comjsounds  to  express  this  idea  seems  superfluous,  unless 
it  be  to  lull  the  spirit  of  inquiry  by  fostering  the  false  belief  that  these 
terms  embody  a  pathological  entity.  It  must  not  be  forgotten  that 
these  terms,  seemingly  so  definite,  and  yet  so  vague,  took  their  rise  at 
a  period  when  the  precise  and  minute  methods  of  investigation  at  present 
in  vogue  were  comparatively  unknown.  These  imposing  terms,  there- 
fore, are  the  reflection  of  imperfect  pathological  knowledge.  They  no 
longer  satisfy  any  but  those  who  are  satisfied  with  the  imperfect  patho- 
logical knowledge  of  the  past.  Advancing  knowledge  has  gradually 
contracted  the  proportion  of  cases  in  which  pain  cannot  be  referred  to 
its  cause.  And  with  this  advance  we  are  less  under  the  necessity  of 
treating  pain  as  an  essential  disease ;  we  are  more  able  to  attack  suc- 
cessfully the  real  disease  of  which  the  pain  is  a  symptom. 

If  then  we  consent  to  retain  the  terms  "  irritable  uterus "  and 
"  hysteralgia,"  it  must  be  because  they  have,  by  long  prescription,  es- 
tablished for  themselves  a  kind  of  footing  in  nosology. 

jSI^euralgia  of  distant  parts,  as  of  the  face  or  breast,  is  often,  if  not 
strictly  symptomatic,  certainly  consequent  upon  uterine  and  ovarian 


100  PAIN. 

disease.  This  dependence  is  often  quite  overlooked  by  physicians  who 
devote  special  attention  to  neuropathy.  Neuralgia,  studied  apart  from 
its  antecedents,  is  apt  to  assume  much  of  the  importance  attached  to  an 
idiopathic  or  essential  disease ;  and  being  treated  accordingly,  it  persists, 
rebellious  against  all  the  artillery  of  the  Pharmacopoeia.  The  follow- 
ing is  the  chronological  history  of  a  large  proportion  of  the  cases  of  neu- 
ralo-ia  in  women.  Uterine  disease,  attended  by  hemorrhagic  and 
leucorrhoeal  discharges,  saps  the  general  strength,  degrades  the  quality 
of  the  blood ;  then  all  the  organs,  especially  those  concerned  in  diges- 
tion and  assimilation,  being  badly  nourished,  perform  their  functions 
imperfectly.  Concurrently  with  this  general  impairment  of  nutrition, 
the  nervous  centres  suffer ;  these  centres  become  extremely  susceptible 
to  the  exhausting  influence  of  pain — and  pain  is  constantly  proceeding 
from  the  uterine  disease.  Thus  the  tone  of  the  nervous  centres  is  con- 
stantly being  worn  down,  and  preparation  is  made  for  every  kind  of 
irregular  or  aberrant  nervous  action.  The  nerves  of  the  face,  breast, 
and  limbs  become  keenly  sensitive  to  external  impressions  of  cold,  and 
to  what  are  called  the  sympathetic  impressions  brought  from  internal 
oro-ans.  Neuralgia  is  the  culmination  of  all  this.  To  cure  it  we  cannot 
depend  upon  quinine,  morphia,  actea,  alteratives,  the  hot  iron,  or  divi- 
sion of  the  nerve ;  we  must  trace  the  disorder  back  to  its  source,  and 
by  curing  the  uterine  disease,  arrest  the  primary  cause  of  the  blood- 
degradation  and  nervous  Avear  and  tear.  This  done,  constitutional 
correctives  and  tonics  will  act  beneficially,  and  we  may  reasonably  ex- 
pect the  neuralgia  to  disappear. 

The  history  of  a  vast  number  of  cases  of  "  hysteria  "  is  exactly  the 
same.  In  short,  hysteria  is  commonly  one  phase  of  aberrant  nervous 
action,  the  result  of  nervous  exhaustion  from  disease  and  mal-nu- 
trition. 

Pains  referred  to  the  uterus,  and  described  as  "  expulsive,"  "  bear- 
ing down,"  likened  to  colic,  generally  indicate  retention  of  fluid,  or 
solid  matter,  in  the  uterine  cavity.  This  explains  the  chief  part  of 
the  pain  of  dysmenorrhoea,  though,  no  doubt,  the  ovaries,  by  their 
direct  participation  in  the  trouble  of  menstruation,  and  by  the  reflected 
distress  from  the  uterus,  contribute  to  the  suffering. 

Pain  referred  to  the  uterine  region,  causing  the  patient  to  bend  the 
body  forward,  is  often  found  in  connection  with  subacute  metritis  and 
subinvolution  of  the  uterus  after  labor. 

Pain  in  the  lumbo-sacral  region  of  a  dull  wearing  character,  attended 
with  more  or  less  impairment  of  the  use  of  the  legs,  is  frequently  as- 
sociated with  retroversion  and  retroflexion  of  the  uterus.  The  pre- 
sumption that  this  displacement  exists  will  be  increased,  if  there  is 
dyschezia  and  habitual  constipation.  The  want  is  proba))ly  not  due  so 
much  to  direct  pressure  of  the  body  of  the  uterus,  even  when  enlarged, 
upon  the  sacral  nerves,  as  upon  the  indirect  pressure  occasioned  by  the 
accumulation  of  hardened  fjeces  in  the  rectum. 

Pain  and  irritability  of  the  bladder  frequently  attend  ante  version  of 
the  uterus,  or  pressure  from  the  uterus  enlarged  by  fibroid,  or  the  ad- 
vance of  cancer.  It  may  also,  of  course,  be  the  consequence  of  dis- 
ease of  the  bladder  or  urethra. 


y  PAIN.  101 

Pains  extending  down  the  legs,  especially  if  attended  with  sensation 
of  numbness  and  a  degree  of  motor  paralysis,  is  presumptive  evidence 
of  pressure  upon  the  sacral  plexus  and  other  nerves  in  the  pelvis. 
This  presumption  acquires  greater  force  if  there  be  attendant  oedema 
of  the  feet  and  legs,  indicating  pressure  upon  the  pelvic  and  abdomi- 
nal veins. 

Pains  in  either  side  of  the  pelvis,  described  as  of  a  dragging  char- 
acter, and  attended  often  with  lumbo-sacral  aching,  is  a  frequent  con- 
sequence of  prolapsus.  It  is,  in  all  probability,  due  to  stretching  of 
the  uterine  ligaments. 

A  pain,  described  as  "throbbing,"  and  attended  with  a  sense  of  ful- 
ness, often  precedes  the  onset  of  the  menstrual  flow,  especially  in  women 
who,  from  the  presence  of  tumors  or  other  disease  in  the  uterus,  are 
subject  to  metrorrhagia. 

A  valuable  presumptive  test  of  the  dependence  of  pain  upon  local 
diseases,  especially  inflammation  or  displacement,  is  the  production  or 
aggravation  of  it,  after  exertion  and  fatigue. 

In  some  cases  pain  is  relieved  by  walking  or  by  the  erect  posture, 
and  is  aggravated  by  the  sitting  or  recumbent  postures.  Where  there 
is  uterine  disease,  attended  by  inflammatory  action  or  enlargement, 
the  pain  is  usually  aggravated  in  a  remarkable  degree  by  the  kneeling 
posture. 

Various  reflex  pains  in  distant  parts  are  often  associated  with  uterine 
and  ovarian  disease.  The  dorsal,  lumbar,  and  sacral  pains  have  been 
already  referred  to.  Other  instances  are  the  occipital  headache,  the 
left  hypochondriac  stitch  or  pain,  and  pains  in  the  breasts. 

Pain,  described  as  "pricking,"  "stabbing,"  "shooting,"  usually 
persistent,  is  commonly  considered  to  be  pathognomonic  of  cancer.  In 
the  advanced  stages  of  malignant  disease  pain  of  this  kind  is  not 
unusual.  But  it  is  by  no  means  constant.  Its  presence  cannot  be  ac- 
cepted as  proof  of  malignant  disease,  nor  can  its  absence  be  accepted 
as  proof  of  the  absence  of  malignant  disease.  Physical  examination 
alone  can  solve  this  question.  Pain  must  be  taken  as  an  indication  for 
this  proceeding. 

Pains  in  one  side  of  the  body,  attended  with  sensations  of  numb- 
ness and  pricking,  or  tingling  in  the  arm,  and  especially  of  the  leg  of 
the  affected  side,  constituting  what  might  be  called  pseudo-paralysis, 
are  not  uncommon  at  the  climacteric  age.  They  do  not  indicate 
ovarian  or  uterine  disease,  although  the  two  conditions  are  frequently 
associated. 


102  DYSPAREUNIA. 


CHAPTER  XIII. 

THE  SIGNIFICANCE  OF   "  DYSPAREUNIA,"   INCLUDING 
"VAGINISMUS," 

I  HAVE  ventured  to  introduce  the  term  "  dyspareunia  "  as  a  conveni- 
ent and  concise  description  of  an  affection  which  is  often  the  immediate 
occasion  of  great  physical  and  mental  suffering,  which  is  apt  to  entail 
the  most  serious  disruptions  of  conjugal  relations,  and  which  is  almost 
always  a  symptom  of  some  morbid  condition  that  admits  of  more  or 
less  successful  treatment. 

There  is  no  disturbance  of  function,  no  subjective  symptom  which 
more  imperatively  dictates  resort  to  physical  exploration  than  difficulty 
or  pain  in  the  performance  of  the  sexual  function.  In  the  great  ma- 
jority of  cases  dyspareunia  depends  upon  some  local  imperfection  or 
disease.  In  many  instances  it  is  not  safe  to  neglect  the  warning  which 
this  symptom  gives  of  something  wrong ;  in  many  this  neglect  con- 
demns the  subject  to  the  keenest  agony — agony  not  the  less  hard  to 
bear  because  affection  or  other  motives  too  often  induce  her  to  conceal  it. 

The  causes  of  dyspareunia  may  be  classed  under  the  congenital  and 
the  acquired. 

Under  congenital  conditions  are  ranged  absence  or  imperfection  of 
the  vagina  or  vulva ;  a  dense  unyielding  hymen ;  too  short  a  vagina, 
the  uterus  being  set  too  low  in  the  pelvis,  so  that  the  os  uteri  is  within 
an  inch  or  a  little  more  of  the  vulva ;  undue  length  of  the  vaginal- 
portion,  or  its  projection  as  a  conical  mass  into  the  vagina.  I  lately 
amputated,  at  St.  Thomas's  Hospital,  by  the  galvano-caustic  wire,  a 
redundant  vaginal-portion,  the  cause  of  intolerable  dyspareunia,  with 
complete  relief.  In  the  case  of  the  uterus  being  set  too  low  in  the 
pelvis,  the  vagina  being  short  and  not  easily  distensible,  dyspareunia 
results  from  the  uterus  not  being  able  to  rise  or  retreat  under  the  im- 
pact of  the  male  organ.  Hence  congestion  and  inflammation  not 
uncommonly  arise.  In  many  cases  a  compensatory  condition  is  estab- 
lished in  time,  by  the  gradual  dilatation  of  the  post-cervical  vaginal 
roof.  This  is  developed  into  a  considerable  pouch.  Although  the 
dyspareunia  may  gradually  subside,  these  cases  often  remain  sterile. 

I  have  met  Math  a  form  of  dyspareunia  which,  in  one  case,  gave  rise 
to  the  question  of  seeking  for  a  divorce.  The  pubic  arch  was  unusually 
deep  and  continued  so  far  back  that  tlie  vulvar  fissure  was  carried  far 
behind  the  normal  seat.  In  this  case,  as  in  many  others  where  in- 
effectual or  unsatisfactory  attempts  at  intercourse  have  been  continued 
for  a  long  time,  an  extreme  degree  of  mental  irritability  and  local 
hypersesthesia  had  been  induced. 

Acquired  Causes  of  Dyspareunia. — Amongst  these  are  found :  con- 
traction or  atresia  of  the  vulva  and  vagina,  the  result  of  disease, 


DYSPAEEUNIA.  103 

injury,  or  cicatricial  processes.     Cases  belonging  to  this  order  will  be 
discussed  under  "Atresia." 

*  Almost  all  the  inflammatory  affections  of  the  pelvic  organs  entail 
dyspareunia.  Congestion  and  inflammation  are  commonly  attended 
with  increase  of  nervous  irritability.  Structures  which  in  the  ordinary 
state  evince  little  sensibility  become,  when  congested  or  inflamed,  in- 
tensely painful.  This  is  markedly  the  case  with  the  vaginal-portion. 
Proof  of  this  is  obtained  when  the  finger  presses  upon  it;  by  the 
speculum  when  the.  blades  are  being  expanded,  and  the  ends  chafe 
against  the  inflamed  vaginal-portion  ;  when  in  adapting  a  Hodge  pes- 
sary the  posterior  limb  is  being  pushed  back  across  the  os ;  in  some 
cases,  when  the  patient  is  at  stool  the  solid  motion  pressing  upon  the 
tender  os.  In  all  these  cases  pain  is  complained  of;  it  is  not  sur- 
prising that  coitus  should  also  be  painful. 

When  the  body  of  the  uterus  is  enlarged  from  hypersemia  or  con- 
gestion, dyspareunia  is  an  almost  certain  result.  In  this  case  on 
making  an  examination,  touching  the  vaginal -portion  may  not  evoke 
pain  ;  but  pressure  by  the  finger  upon  the  body  of  the  uterus,  through 
the  roof  of  the  vagina  or  through  the  rectum,  is  almost  sure  to  do  it. 

Inflammation  or  congestion  of  one  or  other  ovary  is  attended  by  the 
same  result. 

A  frequent  cause  of  dyspareunia  is  colpitis  or  inflammation  of  the 
vagina,  no  matter  to  what  the  inflammation  may  be  due.  Thus  in- 
flammation from  blennorrhagia,  or  from  injuries  during  labor,  will 
frequently  render  sexual  relations  intolerable. 

When  colpitis  exists  there  is  often  entailed  a  spasmodic  contraction 
of  the  vagina  which  greatly  intensifies  the  suffering.  This  condition, 
for  which  Dr.  Marion  Sims  proposed  the  name  "Vaginismus,"  is 
exceedingly  distressing.  It  may  be  likened  to  colitis  or  dysentery.  The 
inflammation  excites  spasmodic  contractions  of  the  muscular  coat,  and 
especially  of  the  vulvar  sphincter.  The  friction  of  the  inflamed  mu- 
cous surfaces  against  each  other  under  these  morbid  contractions  is  the 
immediate  source  of  pain,  and  it  increases  the  inflammation  and 
spasm. 

The  cure  of  dyspareunia  here  depends  upon  the  cure  of  the  colpitis. 
This  is  to  be  accomplished  by  "  rest "  in  the  most  comprehensive  sense 
of  the  word.  It  is  mainly  by  its  efficacy  in  securing  rest  from  the  spas- 
modic contractions  of  the  muscular  coat,  that  Dr.  Marion  Sims's  and 
my  instruments  for  keeping  the  walls  of  the  vagina  apart,  act  so  bene- 
ficially. Two  or  three  weeks'  use  of  one  of  these  instruments  during 
the  daytime,  and  lead  lotions  on  removing  it  at  night,  will  often  effect 
a  cure. 

Pelvic  cellulitis  and  peritonitis,  whether  in  the  acute  or  chronic  stage, 
almost  constantly  entail  dyspareunia.  This  is  due  not  only  to  the  in- 
creased sensibility  attendant  upon  inflammation,  but  also  upon  the  loss 
of  mobility  of  the  uterus.  Whenever  the  uterus  is  fixed  at  a  definite 
low  level  in  the  pelvis,  unable  to  retreat  before  the  propulsion  of  the  male 
organ,  dyspareunia  is  an  almost  inevitable  consequence. 

Hence  this  condition  is  frequently  observed  in  cancer  of  the  uterus, 
and  in  fibroid  tumors  affecting  the  lower  segment. 


104  DYSPAEEUNIA. 

Various  conditions  of  the  vulva  are  peculiarly  apt  to  cause  dyspar- 
eunia.  This  is  not  surprising  M^hen  it  is  remembered  that  the  struc- 
tures of  this  part  are  richly  supplied  with  sensitive  nerves,  and  that  they 
have  to  encounter  the  chief  force  and  irritation.  All  the  varieties  of 
inflammation  of  this  part  necessarily  expose  the  patient  to  this  form  of 
suffering.  I  have  known  it  depend  upon  Avascular  excrescence  of  the 
meatus  urinarius,  and  upon  fissure  at  the  fourchette,  and  removed  when 
these  affections  were  cured. 

It  attends  pruritus  and  the  follicular  inflammation. 

But  the  most  severe  distress  is  often  produced  when  the  entire  cir- 
cumference of  the  vulva  is  involved  in  a  peculiar  inflammatory  process, 
which  may  in  many  cases  be  traced  to  violent  or  unskilful  attempts 
at  intercourse. 

In  these  cases  there  may  be  observed  a  dark  red,  angry-looking  ring 
of  inflammation  around  the  orifice,  sometimes  even  abrasions  or  slight 
fissures,  which  easily  bleed  on  touch,  and  generally  the  carunculse  myr- 
tiformes  present  the  appearance  of  swollen  inflamed  excrescences.  This 
local  inflammation  entails  extreme  sensitiveness  or  hypersesthesia ;  the 
slightest  touch  is  intolerable;  the  patient  shrinks  at  the  very  thought 
of  examination,  and  actual  touch  excites  uncontrollable  spasmodic  con- 
striction of  the  part.  This  constitutes  oneof  the  conditions  which  may 
be  included  under  the  general  term  "  Vaginismus,"  although  the  vagina 
itself  immediately  beyond  the  vulva  may  be  quite  free  from  disease. 
In  some  cases  of  this  kind  it  is  almost  certain  that  there  has  never  been 
complete  intercourse.  Indeed,  where  this  condition  is  developed  at  the 
outset  of  married  life,  the  dyspareunia  and  spasmodic  contraction  are  so 
acute  that  complete  intercourse  is  all  but  impossible.  The  distress,  so 
long  as  the  patient  continues  exposed  to  attempts  at  intercourse,  is  gen- 
erally aggravated  by  time ;  health  breaks  down  under  the  nervous  ex- 
haustion produced  by  repeated  suffering,  and  what  may  be  called  the 
disappointment  of  Nature  under  an  unfulfilled  function.  In  some  cases 
the  irritability  of  the  nervous  centres  becomes  so  great,  the  sensitive- 
ness of  the  peripheral  nerves  at  the  vulva  so  acute,  and  reflex  action 
thereby  so  intensified,  that  the  attempt  at  intercourse  will  induce  con- 
vulsion, or  be  followed  by  syncope.  Exaggerated  emotions,  the  conflict 
between  affection  and  the  dread  of  pain,  may  induce  similar  results. 

Sometimes  vaginismus  is  due  to  the  presence  of  small  fissures  or  sores 
on  the  edge  of  the  perineum  or  vulva.  These  cases  are  analogous  to 
those  of  spasmodic  contraction  of  the  anus  from  similar  causes.  Courty 
relates  a  case  which  he  cured  by  forcible  stretching  by  the  fingers  under 
chloroform.  Vaginismus  and  dyspareunia  may  also  be  occasioned  by 
disease  of  the  rectum,  as  fistula,  or  fissure,  or  inflamed  piles.  Indeed, 
these  reflected  consequences  are  sometimes  so  much  more  extensive  than 
is  the  direct  distress  at  the  seat  of  mischief,  that  the  true  origin  of  the 
pain  is  apt  to  be  overlooked. 

It  may  arise  from  a  vascular  or  irritable  tubercle  of  the  meatus  uri- 
narius. 

In  some  cases  no  lesion  of  surface,  no  inflammation  can  be  discovered ; 
and  we  are  driven  to  the  conclusion  tluit  the  spasmodic  irritability  is 
due  to  hysteria,  or  simple  hypersesthesia,  or  to  emotional  influences. 


DYSPAEEUNIA.  105 

The  cure  of  this  painful  affection  obviously  depends  mainly  upon  a 
period  of  rest,  that  is,  suspension  of  all  attempts  to  renew  sexual  inter- 
course. The  exhausted  nervous  system  must  have  time  and  opportunity 
to  recruit,  the  general  health  must  be  restored,  and  the  local  source  of  irri- 
tation must  be  relieved.  To  accomplish  the  last  indication  various 
measures  are  useful.  In  a  first  order  of  cases  of  minor  severity,  such 
as  are  not  unfrequent  during  the  first  few  days  of  married  life,  a  few 
days'  rest,  fomentations  with  warm  water,  or  tepid  hip-baths,  and  the 
use  of  lotions  or  injections  of  subacetate  of  lead,  may  be  sufficient. 

In  a  second  order  of  cases  of  longer  standing  than  the  first,  and 
including  some  cases  where  the  difficulty  has  arisen  after  complete  in- 
tercourse, and  even  after  labor,  the  remedies  mentioned  may  be  most 
usefully  supplemented  by  wearing  for  several  hours  during  the  day  Dr. 
Marion  Sims's  dilator,  or  my  "  vaginal  rest."  The  action  of  these  con- 
trivances is  to  keep  the  irritable  surfaces  apart,  and  thus,  by  avoiding 
the  irritation  of  friction,  to  allow  the  inflammation  to  subside.  They 
also  further  act  beneficially  by  distending  the  vulvar  orifice,  stretching 
the  muscular  sphincter,  thus  wearing  out  spasmodic  contraction,  and 
using  the  parts  to  bear  the  presence  of  a  foreign  body.  Vaginal  pes- 
saries, containing  acetate  of  lead,  belladonna,  bismuth,  borax,  or  zinc, 
and  made  up  with  glycerin,  are  useful  adjuncts. 

In  the  third  and  more  serious  order  of  cases  surgical  intervention 
will  commonly  be  required.  After  subduing  the  acute  inflammation 
by  rest,  fomentations,  and  lead  lotions,  it  may  be  necessary,  if  the  ori- 
fice of  the  vulva  is  found  unusually  small,  to  enlarge  it  by  making- 
two  or  three  incisions  through  the  skin  on  either  side  of  the  fourchette. 
The  subcutaneous  division  of  some  of  the  fibres  of  the  sphincter  vaginse 
has  been  recommended.  This,  if  adopted,  could  be  done  by  passing  a 
tenotomy  knife  under  the  mucous  membrane,  just  where  it  merges  into 
skin  at  the  posterior  edge  of  the  vulva,  near  the  perineum,  and  when 
the  knife  has  penetrated  flatwise  about  an  inch  by  turning  the  edge  on 
and  cutting  outwards  towards,  but  not  through,  the  skin.  A  period 
of  rest  should  follow  this  operation. 

If  there  are  remains  of  hymen,  or  carunculse  myrtiformes,  presenting 
an  inflamed  hypersensitive  condition,  there  is  no  remedy  so  effectual  as 
the  removal  of  these  parts  by  the  scissors.  The  operation  is  performed 
by  putting  the  patient  under  chloroform,  placing  her  in  the  lithotomy 
position  or  in  the  semiprone  position,  with  the  nates  hanging  well  over 
the  edge  of  the  bed  or  operating  table.  Assistants  aid  in  holding  apart 
the  labia  vulvae  by  fingers  or  retractors,  whilst  the  operator,  seizing  a 
portion  of  the  aifected  structures  with  tenaculum  forceps,  snips  them 
away  all  round,  removing,  if  need  be,  a  complete  ring.  The  incision 
should  not  be  deep,  the  aifected  structure  being  generally  quite  super- 
ficial. Some  bleeding  usually  attends.  This  may  be  controlled  by  ice 
and  by  pressure,  or  by  Richardson's  spray  of  ether  or  styptic  colloid. 
Pressure  should  be  applied  by  plugging  the  vagina  with  pledgets  of 
lint  soaked  in  carbolized  oil.  The  plug  may  be  removed  and  renewed 
next  day.  During  the  healing  of  the  surface  it  is  well  to  wear  an 
elastic  vaginal  rest.  At  the  end  of  three  or  four  weeks  a  cure  will 
generally  be  effected. 


106  DYSPAEEUNIA. 

Disappointment  is  apt  to  follow  this  operation  if  the  smallest  caruncle 
or  other  aflPected  portion  be  left.  Almost  as  much  irritation  and  suffer- 
ing may  be  maintained  by  the  presence  of  a  small  remnant  of  diseased 
structure  as  if  the  whole  were  allowed  to  remain.  Hence  the  expedi- 
ency of  carefully  removing  the  entire  circle. 

In  some  cases  where  the  hymen  is  very  dense  and  the  fourchette  is 
thick  and  unyielding,  so  as  to  contract  excessively  the  vulva,  enlarge- 
ment of  the  opening  by  slight  incisions  is  the  least  painful  and  the 
readiest  proceeding. 

Scanzoni,  summing  up  his  own  very  considerable  experience  of  cases 
of  which  vaginismus  was  the  urgent  symptom,  opposes  the  use  of  the 
knife.  He  has  always  succeeded  in  bringing  relief  by  first  subduing 
all  inflammatory  complications,  and  next  by  effecting  gradual  dilata- 
tion by  means  of  graduated  glass  specula  worn  for  short  intervals  at  a 
time.  Dr.  Tilt  prefers  the  proceeding  adopted  in  the  case  cited  from 
Courty,  namely,  of  forcible  stretching.  This  is  carried  out,  the  pa- 
tient being  in  the  state  of  ansesthesia,  by  introducing  the  two  thumbs, 
back  to  back,  and  then  forcibly  distending  the  vulva  for  five  or  six 
minutes. 

I  have  cured  many  cases  by  methods  similar  to  those  used  by  Scan- 
zoni; but  I  have  met  with  cases  where  the  knife  or  scissors  gave,  in 
my  opinion,  not  only  the  quickest  and  most  efficient  relief,  but  also  at 
the  least  cost  of  pain  and  other  distress.  Certainly  the  judicious  use 
of  these  instruments  may  be  far  less  painful  than  forcible  stretching. 

It  is  needless  to  observe  that  inflammation  of  Bartholini's  glands  is 
a  cause  of  dyspareunia  and  vaginismus.  The  swelling  attending  this 
condition  often  nearly  closes  the  vulva,  and  the  pain  is  so  exquisite 
that  the  slightest  touch  is  intolerable. 

The  painful  excrescence  of  the  meatus  urinarius  commonly  entails 
dyspareunia.  In  this  case  the  attendant  dysuria  will  direct  the  physi- 
cian to  the  source  of  the  evil. 

Dyspareunia  may  be  the  result  of  imperfect  or  disproportionate 
development.  This  is  a  form  not  unfrequently  observed  in  girls  who 
marry  too  young.  It  may  also  be  experienced  by  women  who  marry 
late  in  life.  After  the  climacteric,  especially  in  women  who  have  not 
been  accustomed  to  sexual  relations,  the  uterus,  vagina,  and  vulva  un- 
dergo a  kind  of  atrophic  involution,  in  the  course  of  which  the  vagina 
and  vulva  lose  much  of  their  glandular  structure,  and  the  tissues  lose 
elasticity  and  distensibility.  Sexual  relations  under  these  circum- 
stances may  be  not  only  painful  but  even  dangerous.  There  is  a  prep- 
aration in  St.  George's  Museum  of  a  vagina  ruptured  through  the  roof 
by  the  sexual  act. 

The  condition  called  coccygodynia  by  Sir  J.  Simpson  may  also  be  a 
cause  of  dyspareunia. 

It  must  be  remembered  that  dyspareunia  in  women  may  in  many 
cases  be  traced  to  the  other  sex.  Imperfect,  awkward  intercourse  in- 
duces a  chronic,  nervous  irritability,  which  in  turn  renders  approach 
intolerable.  This  is  a  not  infrequent  source  of  distress  in  couples  ill- 
matched  as  to  age  and  physical  strength  and  disposition. 

I  think  it  important  to  insist  that  Avhenever  a  discharge  of  blood 


STEEILITY.  107 

follows  sexual  intercourse,  whether  it  be  accompanied  by  pain  or  not, 
a  local  examination  should  be  instituted.  Bleeding  excited  in  this 
manner  is  often  the  first  indication  obtained  of  the  existence  of  organic 
disease  of  the  uterus  and  vagina ;  and  it  is  superfluous  to  say  that  the 
prospect  of  curing  organic  disease  will,  in  many  cases,  depend  greatly 
upon  seizing  the  earliest  indications. 


CHAPTER  XIV. 

THE    SIGNIFICANCE    OF    STERILITY. 

The  discussion  of  the  significance  of  sterility  naturally  follows  upon 
that  of  the  significance  of  dyspareunia.  It  may  be  stated  as  an  obvious 
general  proposition,  that  dyspareunia  entails  sterility.  Of  course  there 
are  many  exceptions ;  for  although  intercourse  may  be  difficult  and 
painful,  still  it  may  be  accomplished,  and  numerous  cases  prove  that 
complete  intercourse  is  not  necessary  to  impregnation.  But  these  ex- 
ceptions do  not  invalidate  the  general  law  that  dyspareunia  is  an  obstacle 
to  fertility.  This  is  further  proved  by  the  frequent  occurrence  of  preg- 
nancy when  dyspareunia  is  cured.  It  is  not  simply  because  dyspareunia 
so  frequently  involves  the  suspension  or  incomplete  performance  of  the 
sexual  act  that  it  entails  sterility.  Various  conditions,  as  inflammation, 
displacement,  which  produce  dyspareunia,  are  also  often  of  themselves 
obstacles  to  impregnation.  This  is  proved  by  the  fact  that  in  numerous 
instances  these  conditions  entail  sterility,  although  sterility  is  not  com- 
plained of. 

It  is  no  part  of  the  object  of  an  essentially  clinical  work  to  dwell 
upon  the  moral  or  social  aspects  of  this  question.  But  it  is  strictly 
within  the  scope  of  medical  discussion  to  observe  that  sterility  is  not  a 
,purely  negative  evil,  that  is,  the  history  of  sterility  is  not  summed  up 
by  saying  that  it  is  simply  the  negation  of  fertility.  Complete  sexual 
life  in  woman  implies  the  due  succession  of  the  functions  of  ovulation, 
of  gestation,  and  of  lactation.  The  ovaries,  the  uterus,  and  the  breasts 
ought,  in  the  natural  cycle  or  order  to  relieve  each  other.  Where  the 
ovaries  alone  act  continuously  under  the  excitation  of  married  life,  a 
sense  of  an  unfulfilled  function  arises,  which,  in  many  organizations,  is 
likely  to  induce  physical  as  well  as  mental  disturbance.  The  familiar 
saying  that  women  in  a  certain  condition  of  health  would  be  well  if 


108  STERILITY. 

they  could  have  children  is  a  popular  mode  of  expressing  this  physio- 
logical fact. 

Referring  to  the  evils  attending  sterile  marriage,  Dr.  AYest  observes 
that  chronic  ovarian  irritation  and  chronic  congestion  of  the  womb 
leading  to  hypertrophy  and  menorrhagia  are  apt  to  ensue.  This  is 
undoubtedly  true ;  but  I  may  remark  that  these  cases  would  be  less 
frequent,  if  the  necessity  of  dilating  the  narrow  os  externum  uteri  were 
more  generally  recognized.  When  this  is  done,  even  although  preg- 
nancy do  not  follow,  the  injurious  local  aifections  are  much  less  liable 
to  arise.  The  significance  of  sterility,  from  a  medical  point  of  view, 
then  may  be  taken  generally  to  be  painful  or  imperfect  sexual  relations, 
some  disease  of  the  vulva,  vagina,  uterus,  or  ovaries,  or  disability  on 
the  part  of  the  husband.  Sterility  is  in  itself  a  symptom  or  condition 
that  may  call  for  medical  investigation  and  treatment,  apart  from  the 
pain  or  other  symptoms  which  take  their  rise  in  concomitant  diseases. 

In  discussing  the  subject  it  is  necessary  to  bear  in  mind  the  distinc- 
tion between  sterility  in  a  woman  from  conditions  inherent  in  herself, 
and  sterility  with  potential  fertility.  It  would  be  convenient  if  we 
could  differentiate  these  cases  by  the  appropriation  to  each  of  definite 
terms.  Thus  we  might  say  a  woman  was  "sterile"  whose  inherent 
conditions  precluded  her  from  conceiving,  and  we  might  say  a  woman 
was  "  barren  "  who  was  in  every  respect  apt  to  conceive,  but  who  re- 
mained childless,  because,  first,  the  fertilizing  element  was  wanting ;  or, 
secondly,  because  if  she  conceived,  the  ovum  did  not  come  to  maturity. 
We  should  fall  into  grievous  error,  however,  if  we  were  to  conclude 
that  sterility  always  implied  an  abnormal  condition  of  the  sexual  organs 
in  either  the  man  or  the  woman.  jSTumerous  instances  prove  that  sterility 
may  be  relative  only.  Certain  degrees  of  affinity  seem  to  be  unfavora- 
ble to  fertility.  Upon  this  subject  Captain  Galton  has  adduced  many 
most  interesting  and  valuable  historical  and  statistical  illustrations. 
Thus,  he  shows  in  his  book  on  "  Hereditary  Genius  "  how  evil  is  the 
influence  of  consanguineous  marriages.  The  historv  of  the  Ptolemies 
is  especially  striking.  Alexander  the  Great  had  for  half-brother  Ptolemy 
I,  king  of  Egypt.  This  king  had  twelve  descendants,  who  became 
also  kings  of  Egypt,  and  all  were  called  Ptolemy.  They  were  matched 
in  and  in  like  prize  cattle,  but  these  near  marriages  were  unprolific. 
The  inheritance  mostly  passed  through  other  wives.  Ptolem}^  II  mar- 
ried his  niece,  and  afterwards  his  sister;  Ptolemy  IV  married  his 
sister.  Ptolemies  VI  and  VII  were  brothers,  and  they  both  consecu- 
tively married  the  same  sister ;  Ptolemy  VII  also  subsequently  married 
his  niece ;  Ptolemy  VIII  married  two  of  his  own  sisters  consecutively. 
Ptolemy  XII  and  XIII  were  brothers,  and  both  consecutively  married 
their  sister — the  famous  Cleopatra. 

Captain  Galton  also  shows  the  bad  influence  of  marriage  with 
"  heiresses."  Heiresses  are  presumptively  single  children,  the  feeble 
fruit  of  worn-out  stock.  Many  peerages  have  become  extinct  through 
this.  One-fifth  of  the  heiresses  have  no  male  children  at  all,  a  full 
third  have  not  more  than  one  child,  three-fifths  have  not  more  than 
two.  It  has  been  the  salvation  of  many  families  that  the  husband 
outlived  the  heiress  whom  he  first  married,  and  was  able  to  have  issue 
by  a  second  wife.     "  I  look,"  says  Galton,  "  upon  the  peerage  as  a 


STERILITY.  109 

disastrous  institution,  owing  to  its  destructive  effects  upon  our  valuable 
races." 

The  researches  of  Captain  Galton  are  confirmed  by  those  of  Sir  J. 
Simpson  on  the  fertility  of  the  peerage.  Thus  Sir  James  found  that 
out  of  495  marriages  in  the  British  peerage  81  were  without  issue, 
giving  1  in  6.11  as  the  proportion  of  sterile  marriages;  whilst  675 
marriages  in  the  villages  of  Grangemouth  and  Bathgate,  one  being 
agricultural,  the  other  seafaring,  gave  65  sterile,  or  about  1  in  10. 

The  available  materials  for  estimating  the  proportion  of  sterile  women 
are  very  scanty,  so  much  so  that  no  precise  deductions  can  safely  be 
drawn  from  them.  Indeed,  here,  as  in  so  many  other  cases  where  the 
phenomena  of  life  are  concerned,  the  complicating  conditions,  and 
therefore  the  sources  of  fallacy,  are  so  numerous  that  it  is  almost  im- 
possible to  isolate  the  bare  fact  of  sterility,  the  word  being  taken  to 
imply  incapacity,  absolute  or  temporary,  to  bear  children,  in  any  con- 
siderable number  of  instances^  so  as  to  make  up  a  statistical  column, 
all  the  constituent  elements  of  which  shall  have  equal  significance. 
Under  the  usual  statistical  process  there  remains  nothing  but  a  caput 
mortuuin,  from  which  all  the  facts,  all  the  truth,  have  been  sublimed 
away. 

As  a  matter  of  general  political  interest,  however,  it  may  be  stated 
that  Dr.  Farr  calculates  the  mean  fruitfulness  of  marriages  in  England 
in  ordinary  periods  to  be  in  every  100  marriages  420  children,  giving 
an  average  of  4^^^  children  to  every  marriage.  The  subject  is  pursued 
in  many  of  its  bearings  in  Dr.  Matthews  Duncan's  work  on  "  Fecundity, 
Fertility,  and  Sterility." 

All  speculations  and  calculations  of  this  kind  are  obviously  of  little 
use  in  elucidating  medical  problems.  The  practical  physician  deals 
with  the  concrete,  he  has  to  study  the  individual  case  that  comes  before 
him,  to  search  out  the  conditions  associated  with  the  particular  disorder 
for  which  relief  is  sought,  to  endeavor  to  estimate  the  influence  these 
conditions  may  exert  upon  the  disorder,  and  by  removing  as  far  as  he 
can  all  presumed  interfering  conditions,  to  enable  nature  to  resume  her 
course. 

Applying  this,  the  clinical  method,  we  find  that  sterility  in  woman 
may  be  either  congenital  or  acquired;  it  may  be  absolute  and  incurable, 
or  relative  and  temporary.  The  cases  may  be  ranged  under  the  follow- 
ing heads : 

1.  Those  in  which  ovulation  does  not  take  place;  or,  if  taking 
place,  the  escape  of  the  ovule  from  the  ovary  is  prevented.  The  ovary 
may  be  absent,  in  which  case  there  will  probably  be  absence  or  im- 
perfect development  of  the  uterus  also.  The  ovary  may  be  diseased, 
so  that  the  Graafian  follicles,  quoad  their  proper  structure,  may  be 
destroyed.  The  ovaries  may  be  covered  with  false  membranes,  form- 
ing an  investment  through  which  the  ova  cannot  penetrate.  There 
may  be  a  general  or  local  failure  of  nutrition  arresting  the  maturation 
of  ova.  In  such  cases  menstruation  is  generally  absent.  This  con- 
dition may  be  temporary ;  indeed,  it  is  often  cured  by  appropriate 
constitutional  treatment.  It  is  exceptional  for  women  who  do  not 
menstruate  to  conceive.     But  Bischoff  relates  a  case  which  appears  to 


110  STERILITY. 

show  that  an  ovum  may  ripen;  the  menstrual  flow  occur,  and  sterility 
ensue,  because  the  follicle  does  not  burst.  The  ovum  may  decay  in 
the  Graafian  sac.  A  not  uncommon  result  of  protracted  difficulty  of 
ovulation  is  gradual  atrophy  of  the  ovary,  and  hence  entailed  sterility. 
This  fact  is  an  illustration  of  the  general  law,  that  if  an  organ  is  long 
left  idle  it  is  apt  to  degenerate  in  structure,  and  to  lose  its  functional 
capacity.  Scanzoni  further  suggests  that  a  diseased  ovary  may  pro- 
duce diseased  ova. 

2.  Those  in  which  the  ovum  may  mature  and  escape  from  the  ovary, 
but  in  which  its  due  progress  along  the  Fallopian  tube  and  into  the 
uterus  is  prevented.  This  is  the  case  when  the  Fallopian  tubes  are 
absent,  twisted,  or  severed  ;  occluded  by  strictures,  or  false  membranes  ; 
■where  the  fimbriae  are  absent  (Baillie) ;  where  there  is  multiplication 
of  the  abdominal  orifices,  and  pavilions  (Richard) ;  where  the  fimbriae 
are  bound  down  to  neighboring  structures,  so  that  they  cannot  be 
brought  into  apposition  with  the  ovary.  This  was  described  by 
Ruysch.  The  uterus  itself  may  be  absent,  or,  as  Courty  calls  to  mind, 
may  have  no  cavity.  Fibrous  tumors  growing  at  the  uterine  orifices  of 
the  tubes,  blocking  them  up,  or  in  the  walls  of  the  uterus,  especially 
of  its  lower  segment  and  neck,  by  compressing  and  distorting  the 
canal,  may  cause  sterility.  Indeed,  when  fibroid  tumors  exist,  im- 
pregnation is  comparatively  rare. 

3.  Those  in  which  obstruction  is  interposed  to  the  meeting  of  the 
spermatozoa  and  ovum.  This  order  necessarily  includes  the  preceding 
cases ;  for  the  obstruction  which  arrests  the  progress  of  the  ovum  will 
equally  arrest  that  of  the  spermatozoa  in  the  oj)posite  direction.  But 
to  the  causes  which  arrest  the  ovum  must  be  added  those  which  block 
out  the  spermatozoa,  as  atresia,  congenital  or  cicatricial,  of  the  os  uteri, 
vagina,  and  vulva ;  those  which  produce  closure  or  deviation  of  the 
uterine  canal,  as  excessive  involution  or  atrophy,  tumors,  polypus, 
versions,  flexions ;  certain  peculiar  formations  of  the  uterus,  especially 
of  its  vaginal-portion,  as  a  narrow  os  externum,  excessive  length ; 
excessive  hypertrophic  elongation  of  the  vaginal-portion,  whether 
original  or  acquired,  offers  a  decided  obstacle  to  impregnation.  It  is 
a  not  uncommon  cause  of  dyspareunia.  For  this  double  reason  I  have 
amputated  the  part  with  success ;  tolerance  of  the  sexual  function,  im- 
pregnation, and  natural  labor  ensuing.  Dupuytreu,  Huguier,  and 
others  have  related  cases  in  point,  and  Scanzoni  relates  one  in  which 
impregnation  followed  six  weeks  after  amputation  of  the  hypertrophied 
posterior  lip. 

Excessive  development  of  the  labia  vulvae  may  prove  an  obstacle  to 
intercourse.  In  such  a  case  resection  is  indicated,  and  may  be  safely 
performed. 

Some  cases  of  double  uterus  and  vagina,  as  the  following :  Dr.  Laa- 
ser  describes^  the  case  of  a  lady  who  had  been  married  several  years 
without  pregnancy.  On  examination  it  was  found  that  the  finger 
entered  easily  into  a  capacious  vagina  of  normal  length,  which  ended 
above  in  a  nearly  blind  sac.     There  was  only  a  rudiment  of  a  vaginal- 

1  "Monatsschrift  fiir  Geburtskunde,"  1864. 


STEEILITY.  Ill 

portion  without  os  uteri ;  but  there  was  a  longitudinal  septum  forming 
a  smaller  vagina,  which  latter  was  surmounted  by  a  portio-vaginalis 
and  OS  uteri.  It  was  presumed  that  the  uterus  was  also  double.  The 
sterility  was  accounted  for  by  the  blind  vagina  only  being  used,  the 
vagina  connected  with  the  normal  cervix  being  pushed  aside.  The 
septum  Avas  slit,  so  as  to  throw  the  two  vaginae  into  one. 

Inflammatory  diseases  which  induce  hypertrophy,  or  other  changes 
of  structure  or  form, 

4.  Those  in  which  there  is  some  imperfection  in  the  performance  of 
the  sexual  act.  If  A-^elpeau  and  Rainey  be  right  in  their-  view  of  the 
use  of  the  round  ligaments  in  drawing  forward  the  fundus  of  the  ute- 
rus, so  as  to  throw  back  the  os  uteri  into  direct  relation  with  the  penis 
during  ejaculation,  and  if  this  relation  is  as  a  rule  necessary  for  im- 
pregnation, the  reason  why  women  who  are  the  subjects  of  flexions,  dis- 
placements, and  disease  of  the  uterus  are  so  commonly  sterile,  is  partly 
explained.  This  relation  is  absent  in  many  cases  where  the  vagina  is 
unduly  short,  where  the  uterus  seems  set  too  low  down  in  the  pelvis, 
and  where — under  the  effect  of  intercourse — the  vagina  is  gradually 
lengthened  by  stretching  into  a  pouch  extending  considerably  above 
and  beliind  the  os  uteri.  In  many  cases  it  is  not  simply  the  flexion 
which  prevents  impregnation  by  distorting  the  uterine  canal  and 
throwing  the  os  uteri  out  of  relation,  but  the  secondary  accidents,  as 
inflammation  or  congestion,  attended  by  unhealthy  secretions,  which 
act  adversely.  It  is  of  course  necessary  that  the  seminal  fluid  should 
be  retained.  But  there  are  cases,  including  many  in  which  the  vagina 
being  too  short,  shallow,  and  irritable,  it  is  forcibly  expelled  by  spas- 
modic contraction.  It  has  been  said  that  spasmodic  stricture  of  the 
OS  internum  may  cause  sterility ;  but  the  reality  of  this  condition  is 
not  easy  to  prove.  I  have  also  known  many  cases  of  extreme  gaping 
of  the  vulva,  from  laceration  of  the  perineum,  in  which  impregnation 
did  not  take  place  until  the  normal  condition  was  restored  by  operation. 

5.  Those  in  which  unhealthy  secretions  are  formed,  unfitted  for  the 
maintenance  of  the  vitality  of  the  ovum  and  spermatozoa.  Donn6  ob- 
served that  some  kinds  of  vaginal  secretion  instantly  killed  the  sperma- 
tozoa. The  qualities  shown  to  be  uncongenial  are  excessive  alkalinity 
of  the  cervical  mucus,  excessive  acidity  of  the  vaginal  mucus,  the  mu- 
cus of  uterine  catarrh,  and  other  abnormal  secretions ;  indeed,  any  se- 
cretion excessive  in  quantity,  amounting  to  leucorrhoea,  is  also  likely  to 
have  an  unfavorable  effect.     Menorrhagia  is  often  attended  by  sterility. 

Sterility  where  a  vesico-vaginal  fistula  exists  is  not,  of  course,  a  nec- 
essary result,  but  it  is  nevertheless  frequent. 

Treatment. — Examining  the  foregoing  summary  of  causes  from  a 
therapeutical  or  practical  point  of  view,  it  will  be  seen  that  there  is  one 
order  of  cases  in  which  the  sterility  is  absolute  from  defect  of  structure 
or  other  conditions  which  cannot  be  removed,  and  which  render  im- 
pregnation impossible.     The  number  of  such  cases  is  not  great. 

We  see  another  order  of  cases  in  which  there  exists  some  mechanical 
obstacle,  congenital  or  acquired,  which  may  be  removed  by  surgical 
operation.     The  number  of  these  cases  met  with  in  practice  is  consid- 


112  STERILITY. 

erable.  Fecundity  in  these  exists  potentially.  It  is  only  necessary  to 
remove  the  obstructions. 

We  see  another  order  of  cases  in  which  actual  proof  of  fecundity  has 
been  given  by  the  birth  of  a  child.  With  this  one  eifort  the  capacity 
seems  to  be  exhausted,  at  least  for  a  time.  This  is  "  acquired  sterility." 
This  condition  is  in  some  cases  due  to  excessive  involution  of  the  ova- 
ries and  uterus,  which  shrinking,  appear  to  undergo  premature  senility. 
In  other  cases  it  is  due  to  the  flexions,  hypertrophies,  subacute  inflam- 
mations attended  by  unhealthy  secretions  which  sometimes  follow  labor. 
In  these  the  sterility  commonly  ceases  with  the  cure  of  the  abnormal 
condition.  In  some,  however,  in  which  there  has  been  pelvic  periton- 
itis, the  ovaries  and  tubes  may  have  been  involved  in  membranous  ad- 
hesions which  impede  the  escape  of  ova  or  their  reception  into  the  tubes. 
But  it  must  not  be  supposed  that  pelvic  peritonitis  is  at  all  a  necessary 
cause  of  sterility.  I  have  known  many  cases  where  there  was  no  in- 
terruption to  sulDsequent  pregnancies.  Peritonitis  may  cause  temporary 
sterility  by  binding  down  the  uterus  in  an  unfavorable  position,  espe- 
cially in  retroversion.  This  will  often  admit  of  cure  by  wearing  a  suita- 
ble lever-pessary,  which,  constantly  tending  to  lift  up  the  fundus,  puts 
the  adhesions  on  the  stretch,  and  gradually  causes  their  removal  by  ab- 
sorption. 

6.  Those  cases  in  which  the  mucous  membrane  of  the  uterus  is  un- 
fitted to  afford  a  nidus  for  the  impregnated  ovum.  Thus  there  is  a  class 
of  cases — and  it  is  a  large  one — in  which  pregnancy  fails,  not  because 
there  is  an  obstacle  to  impregnation,  but  because  the  structures  upon 
which  the  ovum  should  be  grafted  and  supported  are  not  in  a  condition 
to  perform  their  part.  In  such  an  event  the  ovum,  falling  as  it  were 
upon  bad  soil,  decays.  The  break-down  occurs  at  variable  periods.  In 
many,  probably,  the  ovum  hardly  gets  any  hold  of  the  unhealthy  mu- 
cous membrane  or  decidiia.  In  many  others,  the  mucous  membrane 
undergoes  the  proper  development  for  a  stage,  then  breaks  down.  In 
many  cases  also  there  is  little  doubt  that  the  ovum  itself,  although  im- 
pregnated and  ingrafted  on  the  decidua,  perishes  from  inherent  defect. 
We  thus  see  how,  by  a  large  class  of  cases,  sterility  is  brought  into  re- 
lation with  abortion.  It  may  seem  paradoxical  to  say  that  many  of  the 
causes  of  sterility  are  also  causes  of  abortion ;  but  the  proposition  is 
nevertheless  true.  Some  of  the  conditions  above  described,  such  as  a 
minute  os  uteri  externum  and  flexions  of  the  uterns,  do  not  oppose  ab- 
solute obstruction  to  impregnation.  But  when  this  occurs,  especially 
in  the  case  of  retroflexion,  abortion  is  very  apt  to  ensue.  The  same  is 
true  of  hypertrophy,  engorgement,  ulceration,  attended  or  not  with  dis- 
placement. In  these  conditions  impregnation  is  not  very  rare,  but  the 
unhealthy  state  of  the  organ  will  be  apt  to  lead  to  abortion.  There  is 
a  kind  of  hyperplasia  of  the  mucous  membrane,  sometimes  depending 
upon  a  strumous,  sometimes  upon  a  syphilitic  diathesis,  which  is  very 
unfavorable  to  the  support  of  tlie  impregnated  ovum.  It  is  liable  to 
undergo  fatty  degeneration  and  to  break  down.  Abortion  is  the  result ; 
and  when  this  happens,  as  it  often  does,  repeatedly,  other  chronic 
changes,  as  hypertrophy,  engorgement,  are  more  and  more  likely  to  en- 
sue, and  to  add  new  obstacles  to  impregnation  and  gestation. 


STERILITY.  113 

Ovarian  irritation  is  also  likely  to  cause  sterility  and  early  abortion, 
especially  when  it  leads  to  menorrhagia.  Excessive  and  prolonged  flow 
will  so  alter  the  mucous  membranes  that  it  becomes  unfitted  to  form 
healthy  decidua.  And  if  impregnation  have  occurred,  the  ensuing  men- 
strual nisus,  too  powerful  to  be  controlled  by  the  pregnancy,  may  be 
attended  by  a  profuse  hemorrhage  which  brings  about  extravasation 
into  the  decidua,  or  such  other  disturbances  in  the  uterus  as  are  incom- 
patible with  the  maintenance  of  the  ovum.  In  many  cases  of  this  class 
it  is  difficult  or  impossible  to  determine  whether  impregnation  have 
taken  place  or  not,  that  is,  whether  or  not  the  case  be  one  of  early  abor- 
tion. The  practical  result,  however,  is  the  same,  and  the  indication  for 
treatment  is  the  same.  Correct  the  unhealthy  state  of  the  uterine 
structures,  allay  the  morbid  irritability  of  the  ovaries,  and  not  only  will 
impregnation  be  likely  to  occur,  but  the  ovum  may  be  supported  and 
matured. 

By  far  the  most  common  associated  conditions  with  sterility,  in  my 
experience,  are  congenital  narrowing  of  the  os  externum  and  retroflex- 
ion of  the  uterus.  These  conditions  are  frequently  combined.  They 
are  commonly  attended  by  dysmenorrhoea ;  and  dysmenorrhoea  is  often 
presumptive  of  sterility.  The  importance  of  this  narrowing  of  the  os 
externum  uteri  as  an  obstacle  to  impregnation  is  questioned  by  some 
physicians,  and  amongst  others  by  Scanzoni.  He  urges  that  he  has 
known  impregnation  take  place  where  the  os  externum  was  no  bigger 
than  a  millet-seed.  Of  this  I  too  have  seen  examples,  but  I  am  satisfied 
from  very  extensive  observation  that  these  cases  are  quite  exceptional. 
So  preponderating  is  the  association  of  a  minute  os  externum  and  retro- 
flexion, separately  or  combined,  that  in  any  given  case  of  a  woman  who 
remains  sterile  five  years  after  marriage  and  suffers  from  dysmenor- 
rhoea, it  may  be  predicated  with  almost  certainty  that  one  or  other  of 
these  conditions  exists.  That  these  are  efficient  causes  of  sterility  is 
further  proved  by  the  frequency  with  which  pregnancy  follows  upon 
their  removal.  Of  this  I  have  seen  many  striking  examples.  Two 
sisters,  both  young,  were  referred  to  me  by  their  brother,  a  former 
pupil.  Both  had  always  suffered  from  dysmenorrhoea,  which  had  been 
increased  by  marriage,  and  both  remained  sterile  after  two  to  four . 
years.  In  both  I  found  exactly  the  same  congenital  formation,  namely, 
retroflexion  of  the  uterus  and  a  minute  os  externum.  In  both  I  divided 
the  OS  externum  and  corrected  the  retroflexion  by  the  use  of  a  Hodge 
pessary.  Both  were  relieved  of  the  dysmenorrhoea,  became  pregnant, 
and  bore  children.  This  subject  will  be  further  discussed  under  the 
head  of  "Dysmenorrhoea." 

The  waters  of  Schwalbach  and  Kreuznach  have  acquired  a  certain 
reputation  for  the  cure  of  sterility.  It  is  true  that  a  number  of  women 
have  become  pregnant  after  visiting  these  places;  but  I  have  good  rea- 
son for  saying  that  in  some  of  them  at  least  the  happy  result  was  not 
due  to  using  the  waters.  Some  had  previously  tried  them  in  vain,  and 
having  subsequently  been  submitted  to  surgical  treatment  for  the  re- 
moval of  physical  impediment,  had  returned  to  ScliAvalbach  or  Kreuz- 
nach, and  then  conceived.  In  some  cases,  however,  those  for  example 
which  depend  upon  chronic    engorgement  or  hypertrophy,  with  un- 


114  STERILITY. 

healthy  secretions,  the  influence  of  change  of  air,  repose,  and  the  use  of 
saline  chalybeate  and  iodized  M^aters  in  curing  these  conditions  is  de- 
cided ;  and  these  being  cured,  the  attendant  sterility  will  often  disap- 
pear. With  this  qualification,  I  can  speak  well  of  Schwalbach,  Kreuz- 
nach,  and  other  places ;  but  they  do  not  deserve  the  blind  faith  which 
many  patients  and  some  physicians  award  to  them.  The  rational 
course  is  to  remove  all  abnormal  local  conditions  first,  and  then,  but 
not  till  then,  the  patients  may  be  sent  to  Schwalbach  or  other  con- 
venient place  for  time  to  do  the  rest. 

The  above-mentioned  conditions  account  for  a  large  proportion  of 
the  cases  of  sterility.  All  these  conditions  may,  in  the  majority  of  in- 
stances, be  remedied,  and  in  all  the  prospect  of  impregnation  is  rea- 
sonable. That  disappointment  in  this  respect  will  occasionally  follow, 
even  when  a  detected  associated  morbid  condition  is  removed,  is  no 
valid  argument  against  treatment.  It  is  sound  practice  to  remove 
every  abnormal  condition  we  can.  It  is  possible  that  any  given  abnor- 
mal condition  which  we  discover,  and  which  we  know  is  in  itself  suffi- 
cient to  entail  a  certain  result,  may  be  the  only  cause.  It  is  of  course 
possible  that  another  cause  lying  beyond  the  first  may  coexist,  and  con- 
tinue after  the  first  is  removed;  but  there  is  no  harm  done  in  removing 
the  first.  On  the  contrary,  the  first  detected  condition  is  often  the 
cause  of  other  evils  beside  the  particular  one  which  it  is  our  special  ob- 
ject to  cure ;  and  it  not  infrequently  happens  that  the  removal  of  one 
condition  opens  the  way  to  the  discovery  and  cure  of  other  conditions. 

In  short,  the  obvious  principle  of  acting  is  to  obtain  as  healthy  a 
state  as  possible  of  the  genital  organs.  The  vulva,  vagina,  and  uterus, 
and  in  some  cases  the  Fallopian  tubes,  are  within  our  range.  When 
this  portion  has  been  brought  into  a  satisfactory  state,  and  when  all 
morbid  action  of  the  ovaries  has  been  subdued,  we  shall  have  overcome 
a  very  large  proportion  of  the  causes  of  sterility.  The  residuum  wall 
comprise  those  cases  of  obstruction  from  adhesions  of  the  tubes  and 
ovaries,  of  ovarian  disease  or  defective  development,  which  are  mostly 
beyond  the  reach  of  successful  treatment. 

Sterility  being,  in  so  far  as  the  fault  lies  in  the  woman,  a  consequence 
of  some  abnormal  condition  of  the  sexual  organs,  the  treatment  of  it  is 
involved  in  the  treatment  of  these  abnormal  conditions.  These  cover 
a  wide  range  of  ovarian  and  uterine  pathology,  and  form  the  subject- 
matter  of  this  work. 

Sensual  gratification  is  not  necessary  to  conception ;  neither  does  its 
absence  preclude  conception.  The  essential  condition  is  that  the  fer- 
tilizing element  should  have  ready  entrance  to  the  cervix  uteri  at  the 
right  time.  Failure  in  this  condition  may  result  from  a  variety  of 
causes  in  persons  to  whom  no  fault  of  structure  in  the  ovaries  or  uterus 
can  be  found.  Ovulation  may  be  perfect,  the  Fallopian  tubes  and 
uterus  may  be  healthy,  the  elements  on  both  sides  may  be  normal,  and 
yet  there  may  be  persistent  sterility.  It  is  difficult  to  follow  out  this 
subject  minutely.  Some  of  the  conditions  referred  to  hardly  fall  within 
the  scope  of  strictly  medical  discussion. 

It  is  not,  however,  out  of  place  to  remember  that  the  cause  of  sterility 
may  reside  in  the  man.  It  is  customary  to  say  that  sterility  in  man  is  ex- 


THE    aYNJECOLOGIST's     BAG.  115 

tremely  rare.  I  am  inclined  to  think  otherwise.  It  does  not  fall  within 
the  design  of  this  work  to  investigate  the  causes  of  sterility  in  the  male 
sex.  But  I  may  refer  to  a  memoir  by  Mr.  Curling^  for  some  interest- 
ing information  on  this  subject.  He  confirms  by  precise  observations 
the  opinion  expressed  by  John  Hunter,  "  that  when  one  or  both  testicles 
remain  through  life  in  the  belly,  they  are  exceedingly  imperfect,  and 
probably  incapable  of  performing  their  natural  functions."  Thus,  Mr, 
Curling  shows  that  in  cryptorchids  the  seminal  fluid  is  commonly  desti- 
tute of  spermatozoa.  In  nine  men  this  was  ascertained  to  be  the  case, 
and  their  wives  were  barren.  Several  of  these  did  not  seem  to  be  de- 
ficient in  copulative  power,  and  emissions  occurred. 

When,  therefore,  we  find  no  marked  abnormity  in  the  wife,  we  must 
consider  the  possibility  of  defect  in  the  husband  ;  and  it  will  be  proper, 
before  subjecting  her  to  a  distressing  and  perhaps  painful  course  of 
treatment,  to  ascertain  whether  the  fault  is  not  on  the  other  side. 


OHAPTER  XV, 

THE  INSTKUMENTS  SERVING   FOR   DIAGNOSIS  AND  TREATMENT. 

Having  taken  a  cursory  survey  of  the  principal  symptoms,  chiefly 
subjective,  attending  ovarian,  uterine,  and  vaginal  disease,  the  methods 
of  investigation  by  which  we  bring  out  the  objective  signs  and  seek  to 
establish  a  full  diagnosis  might  now  be  described.  But  as  the  means 
to  be  employed  in  this  investigation  involve  the  use  of  instruments,  I 
have  thought  this  would  be  the  most  convenient  place  to  introduce  a 
description  of  the  instruments  employed  and  the  mode  of  using  them. 
Having  become  acquainted  with  our  tools,  and  knowing  what  they 
can  do,  we  shall  then  be  in  a  better  position  to  proceed  to  diagnostic 
analysis. 

The  Gyncecologisfs  Bag. 

.  It  will  serve  the  purpose  of  order  and  conciseness  if  we  gather  into 
one  view  the  chief  instruments  and  materials  employed  in  the  diag- 
nosis and  treatment  of  the  diseases  of  women.  This  may  be  conveni- 
ently done  by  describing  the  contents  of  the  gynaecologist's  bag,  which 
has  been  designed  on  the  idea  of  the  "  obstetric  bag "  contrived  by 
me  some  years  ago.  Independently  of  reasons  of  economy  and  method 
for  collecting  all  these  things  into  one  compact  portable  case,  stands 

'  Brit,  .arad  For.  Med  -Ohir.  Review,  1«64. 


116  THE  gy:n^cologist's   bag. 

the  great  practical  fact  that,  when  about  to  investigate  a  case  of  pre- 
sumed ovarian,  uterine,  or  vaginal  disease,  we  cannot  tell  what  instru- 
ments we  may  want  to  carry  out  the  indications  in  diagnosis  and  treat- 
ment which  may  present  themselves.  For  example,  all  local  examina- 
tion necessarily  begins  with  the  digital  touch  ;  this  may  be  sufficient, 
but  often  it  gives  information  which  is  imperfect,  and  which  requires 
to  be  followed  out  by  the  speculum  or  sound;  and  when  we  have  got 
the  full  diagnostic  knowledge  which  finger,  speculum,  and  sound  can 
give,  it  frequently  happens  that  we  are  immediately  in  a  position  to 
apply  an  appropriate  remedy.  Thus  diagnosis  is  made  the  true  hand- 
maid of  treatment.  The  patient  is  often  spared  the  double  distress  of 
two  separate  examinations.  It  is  in  this  quality  that  lies  the  highest 
recommendation  of  the  diagnostic  instruments  we  employ ;  it  is  this 
quality  which  invests  them  with  a  practical  superiority  over  most  of 
the  instruments  employed  in  the  investigation  of  diseases  of  other 
parts  of  the  body.  The  stethoscope,  for  example,  an  instrument  invalu- 
able, but  not  absolutely  indispensable,  for  diagnosis,  and  thus  helping 
to  form  a  scheme  of  treatment,  is  of  no  use  in  carrying  out  the  treat- 
ment. Like  the  sphygmograph  or  the  thermometer,  it  is  purely  an 
instrument  of  observation. 

It  would  appear  to  be  a  natural  classification  of  our  appliances  to 
divide  them  into  diagnostic  and  therapeutical.  Rigorous  adherence  to 
this  is  defeated  by  the  double  qiiality  which  some  of  the  instruments 
possess.     But  still  this  division  is  rational  and  convenient. 

It  is  not,  perhaps,  superfluous  to  preface  the  enumeration  and  de- 
scription of  instruments  by  recalling  attention  to  the  hand  and  eye  of 
the  physician.  The  eye,  of  course,  is  simply  an  instrument  of  observa- 
tion ;  its  application  is  often  only  possible  when  aided  by  other  instru- 
ments, as  for  instance,  the  speculum ;  and  in  a  great  many  cases  it  is 
not  wanted  either  for  diagnosis  or  treatment.  But  the  hand  is  pre- 
eminently the  obstetric  instrument;  it  possesses  a  wide  diagnostic 
and  therapeutical  range  of  usefulness;  it  is  not  only  in  itself  compe- 
tent to  the  detection  of  many  morbid  conditions,  and  to  the  treatment 
of  some,  but  it  is  also  an  indispensable  element  in  the  use  of  other 
instruments. 

I  have  ventured  to  make  these  remarks  about  the  hand  because  the 
use  of  the  speculum  and  sound  in  diagnosis  is  so  very  great  and  strik- 
ing, that  we  are  apt  to  attach  to  this  more  importance  than  is  really 
due,  and  thence  to  underrate  the  value  of  the  hand. 

The  Diagnostic  Instruments  are : 
The  speculum. 
The  endoscope. 
The  speculum-forceps. 
The  uterine  sound. 
A  flexible  whalebone  sound. 
The  sponge  or  laminaria-tent. 

The  Therapeutical  Instruments  are : 
The  uterine  sound. 
The  catheter. 


THE    gynecologist's    BAG.  117 

The  speculum-forceps, 

Simpson's  metrotome-knife. 

Marion  Sims's  or  Kiichenmeister's  metrotome-scissors. 

Wright's  intra-uterine  expanding  pessary,  or  other  intra-uterine 
pessary. 

Sims's  single  tenaculum-hook  to  hold  the  vaginal  portion. 

A  wire  ecraseur. 

The  intra-uterine  caustic-carrier. 
"  "         ointment-carrier. 

The  tube  for  carrying  sticks  of  sulphate  of  zinc,  or  other  sub- 
stances, into  the  uterus. 

Barnes's  laminaria-tent  carrier. 

A  scarificator. 

EiOuth's  lancets. 

An  intra-uterine  injecting  apparatus. 

A  probang  mounted  with  sponge. 

A  glass  rod  and  a  glass  brush  to  carry  bromine  or  chromic  acid. 

A  syringe  for  washing  out  the  vagina. 

The  most  useful  Ilateria  Medica  are: 
Perchloride  of  iron  (solid). 
Chloroform  and  inhaler  (Skinner's   is  the   most  portable,  and 

very  efficient). 
Chromic  acid,  in  crystals. 
Richardson's  styptic  colloid. 
Bromine  of  caustic  power. 
Carbolic  acid. 
Tincture  of  iodine. 
Acetic  acid,  concentrated. 
Nitrate  of  silver. 
Sticks  of  potassa  cum  calce. 
Sticks  of  sulphate  of  zinc. 
Iodide  of  mercury  ointment. 
Medicinal  pessaries  :    1.  Perchloride  of  iron  pessaries. 

2.  Belladonna. 

3.  Morphia. 

4.  Gallic  acid. 

The  following  articles  should  also  be  at  hand  in  the  bag : 
Cotton-wool,  lint. 
String,  silk. 

Needles,  half-curved,  carrying  silver  wire. 
Forceps  for  holding  needles. 
A  small  collection  of  pessaries.     (The  most  useful  are  three 

sizes  of  Hodge's  lever-pessaries.) 
■  One  or  two  of  Thomas's  pessaries  for  anteversion. 
One  or  two  of  Simpson's  intra-uterine  galvanic  pessaries. 
A  stem-pessary. 

A  vulcanite  intra-uterine  pessary. 
A  Sims's  or  Barnes's  vaginal  rest. 
A  Gariel's  or  other  air  pessary. 


118  SPECULUM. 

The  pessaries  will  be  described  in  a  succeeding  chapter. 
The  stethoscope  and  thermometer  are,  of  course,  the  constant  com- 
panions of  every  medical  practitioner. 

Instruments  for  use  hy  Patients : 

Higginson's  vaginal  syringe. 

Barnes's  speculum  for  self-application  of  vaginal  pessaries,  and 
wool  carrying  solutions  of  lead,  bromine,  &c. 

The  special  requirements  of  particular  cases,  or  the  views  of  the 
practitioner,  will  suggest  further  or  different  things  to  make  up  the 
equipment  of  the  bag.  My  object  is  to  enumerate  those  which  are  the 
most  generally  useful. 

Some  of  the  articles  require  a  more  particular  description.  To  take 
first  the  speculum.  In  private  practice,  the  most  generally  useful  spec- 
ulum is  Fergusson's  glass  tubular  instrument,  silvered  and  coated  with 
vulcanite  (Fig.  30).  The  light  this  gives  is  superior  to  that  which  any 
other  form  of  speculum  can  give;  and  this  is  an  advantage  of  primary 
importance,  for  we  cannot  always  in  the  houses  of  patients  command  a 
good  direct  horizontal  light.  Two  sizes  should  be  kept :  one  of  compara- 
tively large  size  for  women  who  have  had  children,  and  one  of  small 
calibre  for  others.  Both  should  be  six  or  seven  inches  long,  otherwise 
the  vagina  may  not  be  distended  enough  to  bring  the  os  uteri  into  view. 

The  tubular  speculum  has  the  disadvantage  that,  when  introduced 
its  full  length,  it  possesses  no  power  of  increasing  the  distension  of  the 
fundus  of  the  vagina,  so  as  to  bring  out  the  vaginal-portion  from  be- 
hind overlapping  folds  of  a  lax  vagina ;  therefore,  unless  an  instrument 
of  adequate  size  be  used,  it  may  fail  to  exhibit  the  os  uteri.  It  is  also 
liable  to  break  if  it  falls  upon  the  ground. 

Good  valvular  specula  overcome  this  difficulty.  Being  introduced 
their  full  length  in  a  closed  state,  the  blades  can  be  opened  at  their 
extreme  points  so  as  to  stretch  out  the  folds  at  the  roof  of  the  vagina, 
and  thus  bring  the  os  uteri  well  into  the  field,  without  in  any  way 
increasing  the  distension  at  the  vulva.  One  might  devote  a  volume 
to  the  description  of  the  multitude  of  instruments,  each  of  which,  in 
the  estimation  of  its  contriver,  is  the  best.  Some  are  designed  to  an- 
swer particular  indications ;  for  example,  to  be  self-retaining,  to  liber- 
ate the  hands,  and  thus  to  facilitate  the  performance  of  operations. 
This  is  a  good  reason  for  introducing  a  new  speculum.  But  many,  it 
must  be  admitted,  have  no  better  raison  d'etre  than  the  gratification  of 
a  taste  for  novelty,  the  passion  of  mechanical  invention,  or  the  am- 
bition to  associate  something  with  one's  name.  After  studying  many, 
I  am  afraid  to  say  most,  of  these  contrivances,  and  submitting  many 
to  clinical  proof,  I  think  we  may  usefully  retain  the  following :  1.  The 
tubular  glass  speculum  already  described ;  2.  The  bivalve,  known  as 
Coxeter's,  or  Dr.  Henry  Bennet's  (Fig.  31).  This  is  an  excellent 
instrument.  If  furnished  Avith  a  plug,  it  is  very  easy  of  introduction, 
and  the  two  expanding  blades  command  good  access  to  sight  and  sur- 
gical application.  I  have  used  it  for  many  years,  having  made  two 
slight  modifications  in  it,  which  much  facilitate  its  use.     In  its  ordinary 


SPECULA. 


119 


form  this  speculum,  when  closed  for  introduction,  is  a  cylinder,  slightly 
conical,  the  two  blades  being  of  equal  length.  The  practical  defect  of 
this  is,  that  when  the  stem-plug  is  in  situ,  the  projecting  margin — 


Fig.  30. 


Fig.  31. 


Fergusson's  Speculum.    (Half  natural  size.) 


Dr.  Henry  Bennet's  Speculum,  as  modified  by 
Dr.  Barnes.    (Half  size.) 


made  to  fit  on  the  edge  of  the  ends  of  the  blades,  so  as  to  protect  the 
vulva  and  vagina  during  introduction — is  not  easily  released  when  it 
is  wanted  to  withdraw  it ;  it  hangs  upon  the  end  of  one  blade.  This 
awkward  defect  is  overcome  by  flattening  the  cylinder  a  little,  so  as  to 
make  the  closed  instrument  slightly  oval  in  section,  and  also  by  bevel- 
ling off  the  ends  of  the  blades,  leaving  one  slightly  longer  than  the 
other.  The  effect  of  this  double  alteration  is,  that  when  the  operator 
turns  the  plug  on  its  axis,  the  projecting  rim  is  immediately  thrown 
off  the  end  of  the  blades,  and  is  generally  thrown  out  by  the  contrac- 
tion of  the  vagina,  or,  at  any  rate,  is  easily  withdrawn. 

The  total  length  of  this  instrument  should  be  5J  inches,  exclusive 
of  the  plug;  the  circumference  at  the  uterine  extremity,  4  inches;  at 
the  handle  extremity,  5  inches. 

The  bivalve  has  another  advantage  over  the  simple  tube.     As  the 


120 


SPECULUM. 


Fig.  32. 


uterine  ends  of  the  blades  expand,  it  is  not  only  more  easy  to  bring 

the  vaginal  portion  into  the  field,  but  by 
continuing  the  expansion,  the  roof  of  the 
vagina  is  put  on  the  stretch,  and  thus 
pulls  open  the  os  uteri,  exposing  often  a 
considerable  part  of  the  cavity  of  the 
cervix,  and  thereby  much  facilitating  the 
direct  application  of  remedies. 

3.  A  very  useful  form  of  bivalve  is 
that  known  as  Cuseo's  (Fig.  32).  The 
blades  are  wide  and  nearly  flat,  so  that, 
when  brought  together,  they  touch  along 
the  whole  extent  of  their  margins,  and 
represent  a  wedge  with  smooth  edges. 
This  makes  the  plug  superfluous.  It  is 
not,  however,  quite  so  easy  to  introduce; 
some  care  is  requisite  to  keep  off  the 
rather  narrow  edge  from  the  os  pubis. 
When  introduced,  the  screw  at  the  handle 
expands  the  blades  at  the  uterine  end  and 
distends  the  vaginal  roof  in  a  very  effi- 
cient manner.  This  instrument  is  in 
many  cases  self-retaining.  It  is  virtu- 
ally a  double  duck-bill  speculum.  I 
have  found  it  useful  to  increase  by  an 
inch  or  more  the  part  in  which  the  screw 
This  takes  the  hand  clear  of  the  range  of 

vision,  and  the  screw  from  entangling  the  pubic  hair. 

4.  Marion  Sims' s  Single  Duck-bill  or  Spoon  Speculum  (Fig.  33.) — 

This  is  a  most  serviceable  instrument.     It  is  almost  indispensable  in 


Cusco's  Speculum.     (Half  size.) 


is  worked  at  the  handle. 


Fig.  33. 


Sims's  Speculum. 


the  performance  of  protracted  operations,  such  as  the  closure  of  vaginal 
fistulse.  It  is  not,  however,  so  convenient  for  ordinary  practice.  In 
many  cases  an  additional  instrument  to  serve  as  a  retractor  to  hold 
back  the  anterior  vaginal  wall  is  required ;  and  this  makes  an  assistant 
necessary. 


SPECULUM. 


121 


5.  If  there  is  one  speculum  better  than  the  rest  for  hospital  practice, 
it  is  Neugebauer's.  This  consists  of  two  distinct  pieces.  It  is  at  once 
a  bivalve  and  a  double  duck-bill.  It  is  made  in  sets  of  six  or  more 
single  blades,  so  graduated  in  size  that  No.  2  adjusted  with  No.  1  makes 
a  complete  speculum ;  No.  3  with  No.  2,  and  so  on  through  the  series. 
Nos.  1  and  2  form  a  speculum  large  enough  for  the  most  capacious 
vagina;  whilst  Nos.  5  and  6  can  be  introduced  into  the  smallest.  Unless 
the  patient's  nates  can  be  brought  to  overhang  the  end  of  a  table  or  bed, 
in  lithotomy  position,  this  instrument  can  only  be  used  in  the  lateral 
or  semi-prone  position.  It  requires  two  hands,  one  to  hold  each  blade, 
which  is  not  inconvenient  for  mere  diagnosis,  but  renders  it  necessary 
to  have  an  assistant  to  hold  one  blade,  if  treatment  is  to  be  carried  out. 
These  conditions  render  Neugebauer's  instrument  generally  unsuitable 
for  private  practice. 

Fig.  34. 


Barnes's  Modification  of  Neugebauer's  Speculum.    (Half  size.) 


Finding  that,  when  dealing  with  stout  patients,  the  handles  of  Neu- 
gebauer's instrument  were  too  short  to  be  easily  commanded,  I  have 
made  what  I  find  in  practice  a  very  convenient  modification.  I  have 
substituted  for  the  handle  another  blade.  Fig.  34  represents  the  form 
thus  designed  by  me,  and  executed  by  Messrs.  Weiss.  Two  pieces  make 
a  series — three  different  sizes  of  speculum.  The  gradation  is  effected 
by  having  Nos.  1  and  3  in  one  piece,  and  Nos.  2  and  4  in  the  other. 
By  using  No.  1  with  No.  2,  we  get  the  largest  size;  by  using  No.  2 
with  No.  3,  we  get  the  next  size ;  by  using  No.  3  with  No.  4,  we  get 
the  smallest  size.     The  ends  outside  the  vagina  form  excellent  handles. 

In  many  cases  this  instrument  is  sufficiently  self-retaining  to  afford 
the  manipulator  the  opportunity  of  applying  remedies  to,  or  even  of 


122  ENDOSCOPE UTERINE    SOUND. 

performing  operations  upon,  the  cervix  uteri  without  assistance.  It 
gives  freer  space  for  operative  manipulation  than  any  other  speculum. 
It  brings  the  os  uteri  so  near  that  it  is  commonly  easy  to  reach  it  by 
the  finger. 

The  tubular  and  valvular  specula  afford  a  perfect  inspection  of  the 
whole  tract  of  the  vagina  and  vulva.  The  time  for  making  this  in- 
spection is  during  the  withdrawal  of  the  instrument.  As  this  is  slowly 
done,  the  vaginal  walls  close  in  upon  the  retreating  speculum,  and  come 
successively  within  its  field.  Except  in  very  extreme  cases  of  relaxa- 
tion, the  contractility  and  resilience  of  the  vagina  are  powerful  enough 
to  aid  in  expelling  the  sjDeculum. 

Weiss's  Self-retaining  Duck-bill  Speculum. — This  instrument  is  the 
adaptation  of  an  ajDparatus  for  fixing  a  duck-bill  or  Sims's  spoon-blade 
in  the  vagina,  so  as  to  dispense  with  the  use  of  hands  to  hold  it  in  situ. 
In  this  way  many  operations  may  be  conveniently  carried  out  without 
assistants.     I  have  used  it,  and  find  that  it  answers  its  purpose. 

All  the  above-described  specula,  excepting  Fergusson's^  should  be 
plated  with  nickel.  This  gives  a  beautifully  smooth  surface,  which 
resists  the  action  of  many  of  the  corroding  agents  employed,  and  is 
easily  kept  bright. 

The  Endoscope. — In  connection  with  the  speculum,  it  is  proper  to 
refer  to  the  endoscope,  which  may  be  defined  as  a  prolongation  or  ex- 
tension of  the  ordinary  speculum.  The  design  of  the  uterine  endoscope 
is  to  enable  the  surgeon  to  see  beyond  the  os  uteri  externum  into  the 
cavity  of  the  cervix,  and  even  into  the  cavity  of  the  body  of  the  uterus. 
Several  ingenious  instruments  have  been  contrived  for  this  purpose. 
One,  that  of  Jobert,  consists  virtually  of  a  small  two-bladed  speculum, 
capable  of  being  introduced  closed  into  the  cervix  uteri.  The  two  blades 
being  mounted  on  a  long  stem  are,  after  introduction,  made  to  diverge 
by  working  a  screw  in  the  handle.  It  resembles  in  principle  and  ac- 
tion Weiss's  urethra  dilator.  Another  contrivance  that  may  be  men- 
tioned is  that  of  Tyler  Smith.^  This  instrument  is  applied  through  a 
modified  Cusco's  speculum.  It  consists  of  a  mirror  and  a  cylindrical 
tube  both  provided  with  long  handles.  By  means  of  a  screw  the  mir- 
ror can  be  inclined  at  any  angle,  so  as  to  receive  and  transmit  a  ray  of 
light  through  the  tube  which  is  passed  into  the  uterine  cavity. 

The  Uterine  Sound  is  an  instrument  designed  on  the  principle  of  the 
sound  made  to  explore  the  male  bladder.  It  is  a  special  form  of  the 
surgical  probe.  The  probe,  indeed,  or  some  form  of  it,  has  long  been 
used  to  facilitate  the  exploration  of  the  uterus.  Its  application  to  the 
diagnosis  of  polypus  from  inversion  of  the  uterus  is  described  in  the 
early  editions  of  Samuel  Cooper's  "Surgical  Dictionary."  Huguier 
says  the  uterine  sound  was  known  to  Hippocrates.  Harvey  relates  a 
case  in  which  he  used  an  equivalent  instrument  for  the  express  purpose 
of  exploring  the  cavity  of  the  uterus.  But  still  the  application  of 
the  sound  to  uterine  examination,  an  application  which  would  seem  to 
flow  so  naturally  from  the  familiar  use  of  the  instrument  in  investi- 
gating the  condition  of  the  bladder,  remained  in  abeyance  until  it  was 

1  Obstetrical  Society's  Catalogue  of  Instruments,  1867. 


UTERINE    SOUND.  123 

revived  by  Lair,  who  described  a  uterine  sound  in  1828.^  The  late 
Sir  James  Simpson,  in  1843,  made  known  his  conclusions  upon  the 
mode  of  examining  by  help  of  a  uterine  sound  or  bougie,  and  de- 
scribed the  form  of  instrument  he  recommended.  His  instrument  is  the 
one  which  I  have  selected  for  illustration  in  this  work.  It  is  the  one 
which  I  most  frequently  employ.  It  is  provided,  like  the  common 
male  sound,  with  a  flat  handle  to  facilitate  manipulation,  and  termi- 
nates at  its  other  extremity  in  a  rounded  knob  or  bulb,  which  enables 
it  to  ride  more  easily  over  the  rugse  of  the  cervical  canal,  and  lessens 
the  risk  of  injuring  the  uterus.  The  stem  tapers  gradually  from  the 
handle  to  the  knob,  the  thickest  part  being  equal  in  calibre  to  a  No.  8 
catheter,  the  portion  near  the  knob  being  equal  to  a  No.  3  catheter. 
The  exploring  half  of  the  sound  should  be  made  of  silver  only  mod- 
erately alloyed  with  copper,  so  as  to  permit  of  its  being  readily  bent 
by  the  fingers.  Some  are  made  with  virgin  silver.  This  is  too  flexible, 
as  it  is  apt  to  bend  during  use,  especially  in  cases  of  flexion  of  the 
uterus.  The  stem  is  about  nine  inches  long,  and  is  graduated  so  as  to 
indicate  the  depth  to  which  it  may  penetrate.  The  graduation  is 
marked  in  the  figure.  (Fig.  35.)  There  is  one  principal  mark  which 
is  the  most  essential  as  a  standard  of  comparison,  made  by  an  elbow 
or  projection,  just  2 J  inches  from  the  knob.  This  marks  the  normal 
length  of  the  uterine  cavity.  When  the  sound  has  been  introduced 
as  far  as  this,  resistance  is  commonly  felt,  and  we  know,  by  feeling  the 
elbow  on  a  level  with  the  os  externum  uteri,  that  the  knob  is  2  J  inches 
in  the  uterus.  It  is  useful  to  have  a  mark  between  the  elbow  and  the 
knob  half  an  inch  above  the  elbow.  This  is  useful  in  giving  precise 
measurement  where  the  knob  will  not  go  the  full  distance.  Below  the 
knob  the  stem  is  graduated  by  inches.  These  secondary  marks  are 
best  made  by  slight  notches.  There  are  different  ways  of  making  the 
index  marks;  but  as  Simpson  rightly  insists,  the  marks  should  be  so 
made  as  to  be  readily  felt  by  the  finger  in  the  vagina,  so  as  to  admit  of 
being  read  oif  when  the  instrument  is  withdrawn.  The  sound,  as  sold 
in  the  shops,  is  almost  always  bent  at  an  obtuse  angle  at  the  2J  inch 
elbow,  the  two  parts  above  and  below  being  quite  straight.  It  is 
more  convenient  in  practice  to  give  a  slight  curve  to  the  part  above 
the  elbow. 

Yalleix,  Huguier,  and  Kiwisch^  described  forms  of  uterine  sound 
differing  from  Simpson's  chiefly  in  the  mode  of  graduation. 

There  are  cases,  notably  those  where  the  canal  of  the  uterus  is  much 
deviated  by  tumors,  where  the  use  of  the  rigid  sound  is  objectionable. 
In  cases  of  this  nature  it  is  occasionally  more  useful  to  employ  a  flexi- 
ble bougie  or  sound.  An  ordinary  male  bougie  is  very  suitable.  Dr. 
Henry  Bennet  commonly  uses  bougies  of  soft  material,  which  retain 
the  impression  of  any  constriction  they  may  have  passed  through. 
Dr.  Thomas  uses^  a  hard  rubber  sound,  about  12  inches  long,  provided 
with  a  knob  at  the  end  similar  to  the  figure  (Fig.  36),  taken  from  the 

1  "  Nnnvelle  M^thode  de  Traitement  des  Ulceres  de  I'llterus."     Paris,  1828. 

2  "  Klinische  Vortrage."    Prag,  1851. 

3  •'  Diseases  of  Women,"  third  edition.     Philadelphia,  1872. 


124 


UTERINE  SOUND METROTOME. 


instrument  which  I  use.  This  is  made  of  whalebone,  which  is  suffi- 
ciently flexible  and  durable,  and  is  not  likely,  as  the  vulcanite  one  is, 
to  break.     My  instrument  is  15  inches  long,  not  at  all  too  long  to 


Fig.  35. 


Fig,  36. 


Simpson's     Uterine 
Sound.  (Half  size.) 


Fig.  37 


Kiichenmeister's  MetrotomeScissors.    (Half  size.) 


track  the  elongation  of  the  uterine  cavity  produced  by  some  cases  of 
fibroid  tumor. 


METROTOMES ECRASEUR.  125 

The  speGulum-force'ps  should  be  about  12  inches  long,  and  straight. 
It  is  sometimes  made  with  an  angle  between  the  joint  and  the  finger- 
holes,  under  the  mistaken  idea  that  when  straight  the  handles  and 
hand  occlude  the  field  of  the  speculum,  and  interfere  with  accurate 
manipulation.  This  objection  is  not  real.  There  is  a  practical  in- 
convenience in  the  handling  of  a  bent  forceps.  It  will  not,  for  example, 
rotate  handily,  so  as  to  wipe  off  adhering  secretions,  as  the  straight 
forceps  will.  The  instrument  should  be  toothed  at  the  ends,  and 
grooved  longitudinally,  so  as  to  hold  a  rounded  stick  of  nitrate  of 
silver,  or  potassa  cum  calce. 

Metrotomes. — The  instruments  I  employ  to  incise  the  cervix  uteri 
are  Simpson's  metrotome,  and  either  a  scissors  designed  by  myself  or 
Kiichenmeister's.  The  reasons  for  this  preference  will  be  given  when 
discussing  the  operation.  Simpson's  metrotome  is  really  a  bistouri 
cache,  with  a  long  handle.  When  closed,  the  blade  and  its  guard  or 
sheath  form  a  rod  about  the  size  of  a  sound,  which  is  easily  passed  into 
the  cervix  uteri.  When  there,  by  depressing  the  handle  to  an  extent 
determined  by  a  regulating  screw,  the  blade  is  made  to  start  from 
its  guard,  and  cuts  its  way  out.  The  guard  is  sometimes  made 
double,  so  that  the  blade  sinks  back  between  the  two  parts.  This 
is  inconvenient.  Wh^n  the  blade,  after  having  cut,  is  allowed  to  fall 
back  into  its  guard,  the  point  is  apt  to  pinch  a  bit  of  tissue  in  the 
guard,  and  the  witlidrawal  of  the  instrument  is  thus  made  awkward. 
A  single  guard  answers  quite  as  well,  and  is  free  from  this  little  diffi- 
culty.    (See  Fig.  38.)    - 

Barnes's  31etrotome- scissors. — This  is  a  powerful  scissors,  having  one 
blade  probe-pointed  to  pass  into  the  cervix.  The  blades  are  so  made 
as  to  cut  well  at  the  points.  They  are  worked,  not  by  finger-rings,  but 
by  a  spring  between  the  handles,  on  the  plan  of  the  old-fashioned 
sugar-nippers.  The  handles  are  slightly  curved,  so  as  to  enable  the 
operator  to  see  the  cervix  in  the  field  of  the  speculum  whilst  working. 

Kiichenmeister's  3Ietrotome-scissors. — Ordinary  scissors  are  not  well 
adapted  to  make  an  incision  clean  through  a  rounded  wedge-shaped 
body,  which  shall  be  of  equal  depth  at  every  part.  The  blades  are  liable 
to  slide  away  a  little  towards  the  finish  of  the  stroke,  leaving  a  spur 
of  tissue  uncut.  To  remedy  this  I  have  often  completed  the  incision 
made  by  my  scissors  with  Simpson's  metrotome.  But  for  some  years 
I  have  used  Kiichenmeister's  scissors,  one  blade  of  which  is  provided 
with  a  small  recurved  hook.  This  buries  itself  in  the  tissue  as  soon  as 
the  part  is  seized,  and  holds  it  secure  whilst  it  is  being  cut  through. 
The  instrument  answers  well.  (Fig.  37.) 

Sims's  Tenaculum  Hook. — This  is  a  very  useful  little  instrument  for 
seizing  and  holding  steady  the  cervix  uteri  for  examination,  and  during 
operations  through  the  speculum.  (Fig.  39.) 

The  Wire-ecraseur. — Advancing  experience  has  gradually  proved  the 
superior  convenience  of  the  form  of  ecraseur  here  illastrated.  (Fig. 
40.)  For  ordinary  purposes,  such  as  the  removal  of  polypi,  the  single 
wire  is  far  more  convenient  than  the  chain.  The  two  ends  of  the  wire 
are  hooked  on  to  the  hook  Mdiich  travels  in  the  screwed  stem  of  the  in- 
strument.    The  loop  of  wire,  which  has  seized  the  body  to  be  cut 


126 


METROTOME TENACULUM    HOOK. 


through,  is  drawn  through  the  flattened  eye  at  the  end  of  the  stem  with- 
out any  sawing  movement.  This  involves  a  considerable  loss  of  power; 
but  in  the  majority  of  cases  this  is  of  no  importance.     An  advantage 


Fig.  38. 


Simpson's  Metrotome. 


Fig,  39. 


Sims's  Tenaculum  Hook. 


possessed  by  this  arrangement  is  that  a  much  longer  loop  can  be  worked, 
since  the  loop  comes  down  double ;  whereas,  when  one  end  of  the  loop 
is  fixed,  and  only  one  travels,  the  travelling  end  may  be  brought  home 


^CEASEUR TENT-CAERIEE. 


127 


too  soon,  that  is,  before  the  loop  has  cut  through  the  tissues  embraced 
in  it.     There  is.  however,  the  advantage  of  a  half-sawing  or  cutting 


Fig.  41. 


Improved  Wire  Ecraseur 


Barnes's  Instrument  for  Introducing  Laminaria  or 

Sponge-tents  into  the  Uterus.  (Half-size.) 
a.  The  hollow  laminaria-tent. 
6.  The  sponge-tent, 
c  c.  The  stilets  upon  which  the  tents  are  mounted. 


action,  which  increases  power.     To  obviate  the  inconvenience  of  the 
ends  of  the  wire  travelling  home  before  the  loop  has  done  its  work, 


128     instrumejS'ts  for  treating  diseased  uterus. 

Messrs.  Weiss  have  constructed  a  very  powerful  ^craseur,  furnished  with 
a  windlass  upon  which  the  wire  is  wound  as  it  is  brought  home.  This 
gives  practically  an  endless  rope.  It  is  a  splendid  instrument ;  and  iu 
some  cases  it  will  succeed  where  ordinary  instruments  will  fail.  To  cut 
through  large  fibroid  tumors  a  very  powerful  instrument  is  necessary. 

The  Laminaria  and  Sponge-tent  Carrier. — This  is  a  very  useful  in- 
strument, contrived  by  me  some  years  ago,  to  carry  laminaria-tents  into 
the  uterus.  It  consists  of  a  piece  of  elastic  catheter  having  the  end  cut 
off,  so  that  the  stilet  may  project  about  two  inches.  Upon  this  portion 
of  stilet  the  tent,  which  is  hollow,  is  mounted.  It  thus  makes  one  with 
the  catheter,  and  can  be  passed  into  the  uterus  nearly  as  easily  as  the 
uterine  sound.  When  the  tent  is  in  situ,  which  is  ascertained  by  the 
guiding  finger  at  the  os  uteri,  the  stilet  is  withdrawn ;  the  unsupported 
tent  is  then  left  in  the  uterine  canal.  This  description  shows  that  an 
efficient  instrument  can  be  improvised  out  of  a  catheter.  But  it  is  con- 
venient to  have  a  special  instrument.  (Fig.  41.)  Mine  is  provided 
with  two  sizes  of  stilets,  which  screw  into  the  stem  ;  also  with  a  pointed 
stilet  to  carry  sponge-tents.  These  stilets  are  stowed  in  the  handle, 
which  is  hollow.  At  the  handle-end  of  the  catheter  or  tube  is  a  disk 
or  shield  which  gives  a  point  of  resistance  for  the  thumb,  when  the 
handle  and  stem  are  withdrawn.  (Fig.  41.) 

The  same  instrument  can  be  adapted  to  introduce  Simpson's  galvanic 
and  other  intra-uterine  pessaries. 

The  Intra-uterine  Caustic  Carrier. — My  contrivance  for  the  applica- 
tion of  nitrate  of  silver  to  the  os  and  interior  of  the  uterus  is  an  adap- 
tation of  a  plan  which  I  learned,  when  a  student,  from  Sir  Benjamin 
Brodie.  This  illustrious  surgeon  used  to  arm  the  end  of  a  silver  probe 
by  dipping  it  into  fused  nitrate  of  silver.  With  the  probe  thus  armed 
he  could  cauterize  a  fistulous  tract.  I  have  had  made  a  long  probe 
mounted  on  a  handle.  The  last  three  or  four  inches  should  be  made  of 
silver,  platinum,  or  aluminium,  so  as  to  be  flexible,  as  it  is  often  con- 
venient to  give  a  curve.  The  extreme  end  should  be  roughened  so  as 
to  hold  the  fused  caustic  better.  To  arm  it,  proceed  as  follows  :  Fuse 
about  half  a  drachm  of  nitrate  of  silver  in  a  watch-glass  or  platinum 
crucible,  over  a  spirit-lamp  or  small  gas-flame ;  dip  into  the  fused  caus- 
tic the  end  of  the  probe  several  times,  so  as  to  get  several  layers  upon 
it.  The  probe  should  be  moderately  warmed  in  the  flame  before  dip- 
ping, or  the  nitrate  of  silver  will  be  apt  to  break  off  when  cooled.  (Fig. 
42.) 

By  means  of  this  armed  probe,  caustic  can  be  carried  into  the  cervi- 
cal canal,  and  even  into  the  cavity  of  the  uterus,  without  any  fear  of 
leaving  a  piece  behind.  It  may  even  be  used  without  the  speculum, 
although  in  doing  this,  unless  it  be  guarded  by  a  sheath,  the  caustic  is 
liable  to  touch  the  vulva  in  passing,  and  to  cause  some  irritation  in  con- 
sequence, and  to  blacken  the  surgeon's  fingers. 

The  Tube  for  Carrying  Solid  tSubstances  into  the  Uterus. — To  apply 
sulphate  of  zinc,  chlorate  of  potash,  and  some  other  substances,  it  is 
Very  convenient  to  fuse  them  into  slender  sticks  of  a  given  weight.  To 
introduce  these  sticks  into  the  uterus  through  a  speculum  by  help  of  a 
forceps  is  a  needlessly  troublesome  and  sometimes  difficult  proceeding. 


INSTEUMEISTTS    FOK   TEEATING    DISEASED    UTERUS. 


129 


A  far  more  simple  way  is  to  cut  off  the  end  of  an  elastic  male  cathe- 
ter, to  place  the  stick  in  the  end,  and  then  to  pass  the  catheter  half  an 


Fig.  42. 


}j  a 


Fig  44. 


Barnes's  Nitrate  of  Silver 
Cautery.  (Half  size.) 


Barnes's  Tube  for  Depositing 
Fused  Sticks  of  Sulphate  of  Zinc 
in  Uterus. 


Barnes's  Uterine  Ointment 
Positor. 
The  left-hand  figure  is  full  size.    A, 
the  sliding-piston,  which,  being  pushed 
on  after  the  catheter  is  in  situ,  expels 
the  ointment. 

inch  or  more  into  the  cervical  canal,  as  you  would  a  sound ;   then  by 

9 


130       INSTRUMENTS    FOR   TREATING   DISEASED    UTERUS. 

pushing  up  the  stilet,  the  stick  is  deposited  in  the  uterus,  and  the  in- 
strument can  be  withdrawn.  This  can  be  done  more  easily  without  the 
speculum  than  with  it ;  and  where  an  application  of  this  kind  has  to 
be  repeated  once  or  twice  a  week,  this  is  a  great  advantage,  saving  the 
patient  annoyance  and  fuss,  and  the  surgeon  trouble. 

Instead  of  this  improvised  positor,  it  is  better  to  have  the  special 
instrument  figured.  (Fig.  43.)  This  is  a  silver  or  nickel  tube  fur- 
nished with  a  stilet. 

The  Tube  for  carrying  Ointments,  &c.,  into  the  Uterine  Cavity. — It 
is  often  more  convenient  to  make  applications  to  the  interior  of  the 
uterus  in  the  form  of  ointment.  For  this  purpose  I  have  designed, 
with  the  assistance  of  Messrs.  Weiss,  a  very  handy  instrument.  It  is 
a  long  silver,  nickel,  or  vulcanite  catheter,  having  two  long  eyelet- 
holes  at  the  end,  and  a  conical  well-fitting  piston  or  rod.  It  is  easy  to 
charge,  by  plunging  the  end  of  the  catheter  beyond  the  eyelets  into  the 
ointment,  and  wiping  off  the  superfluity  which  hangs  to  the  outside. 
The  instrument  is  then  passed  like  a  sound  into  the  uterus,  and  then 
the  piston,  being  pushed  forward,  expels  the  ointment  by  the  eyelets 
on  either  side,  leaving  it,  of  course,  in  immediate  contact  with  the 
uterine  mucous  membrane.  This  is  an  especially  useful  way  of  treat- 
ing the  uterine  membrane  affected  by  syphilis.  The  iodide  of  mer- 
cury ointment  is  thus  readily  applied.  (Fig.  44.) 

An  Intra-uterine  Injecting  Appay-atiis. — By  means  of  the  above  con- 
trivances for  depositing  solids  and  ointments  in  the  uterine  cavity,  the 
necessity  for  resorting  to  fluid  injections  is  very  much  restricted.  But 
an  intra-uterine  syringe  is  sometimes  indispensable.  A  good  form  is  a 
small  vulcanite  tube,  having  minute  perforations  at  the  sides — not  at 
the  end — so  that  fluid  projected  may  escape  in  fine  streams  or  drops. 
The  propelling  force  is  best  obtained  by  a  movable  caoutchouc  ball. 

Higginson^s  Syringe  for  Vaginal  Injection  and  Irrigatio7i. — There  is 
no  form  of  vaginal  syringe  more  generally  convenient  for  the  patient's 
own  use  than  that  known  as  Higginson's.  (Fig.  45.)  It  should  be  fur- 
nished with  a  vaginal  tube  four  inches  long. 

Barnes's  Speculum  for  introduction  of  Cotton-ivool  charged  with  Rem- 
edies into  the  Vagina. — The  best  way  of  introducing  pledgets  of  cot- 
ton-wool charged  with  fluids  or  powders  into  the  vagina  is  by  help  of 
the  ordinary  speculum.  But  this  requires  skilled  assistance.  To  en- 
able the  patient  herself  to  carry  out  this  treatment,  I  have  devised  the 
speculum  figured  (Fig.  46),  manufactured  by  Krohne  and  Sesemann. 
It  is  made  of  vulcanite,  a  material  not  injuriously  acted  upon  by  the 
materials  most  frequently  used.  It  consists  of  two  blades,  moving  on 
a  pivot  about  the  middle,  and  a  piston.  The  blades  above  the  pivot 
are  made  to  diverge  by  a  spring  inside;  this  divergence  causes  the 
blades  below  the  pivot  to  come  together,  forming  a  hollow  cylinder  in 
which  the  pledget  of  wool  is  placed.  The  blades  inclosing  the  pledget 
are  further  kept  in  contact  by  a  strong  elastic  ring  outside.  When 
charged,  the  patient,  by  simply  opening  the  vulva,  can  pass  the  in- 
strument into  the  vagina,  directing  the  point  backwards  as  far  as  neces- 
sary; then  by  compressing  the  external  diverging  blades,  the  internal 
ones  are  opened,  and  by  pushing  on  the  piston  or  rod,  the  pledget  is 


INSTRUMENTS    FOR   TREATING    DISEASED    UTERUS.        131 

deposited  in  the  vagina.  The  speculum  is  then  withdrawn  by  leaving 
off  the  compression  upon  the  external  blades.  The  action  of  this  in- 
strument will  be  better  understood  by  an  illustration.  It  was  suggested 
to  me  by  the  ingenuity  of  a  lady  whom  I  had  advised  to  introduce 
pledgets  of  wool  soaked  in  solution  of  bromine.     She  made  use  of  a 


Fig.  45. 


Fig.  46. 


ll 


i^ 


/'\ 


Higginson's  Vaginal  Syringe.    (Half  size.) 


Barnes's  Speculum  (half  size)  to 
facilitate  application  of  Med- 
icated Cotton-wool  in  the  Va- 
gina. 


glove-stretcher  to  separate  the  labia  vulvae,  and  then  slipped  in  the  pled- 
get with  her  fingers.  My  speculum  is  like  a  glove-stretcher,  with  the 
blades  hollowed  to  protect  the  pledget  whilst  passing,  and  a  piston  to 


thrust  it  out  into  the  vagina 


132  DIAGNOSIS. 

The  pledget  of  wool  is  tied  round  with  a  bit  of  string.  This  string 
hangs  outside  the  vulva,  and  by  means  of  it  the  pledget  is  easily  with- 
drawn.    No  pledget  should  be  worn  longer  than  five  or  six  hours. 


CHAPTER   XVI. 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  PELVIC  OEGANS. 
THE  TOUCH— THE  SOUND— THE  SPECULUM. 

The  general  knowledge  we  have  now  acquired  of  the  value  of  sub- 
jective symptoms  and  of  the  instruments  of  diagnosis,  will  enable  us 
to  pursue  with  greater  advantage  those  means  which  bring  out  the 
objective  signs,  and  thus  to  gain  all  the  possible  elements  of  a  complete 
diagnostic  conclusion. 

One  guiding  rule  should  be  impressed  upon  the  mind  of  the  young- 
practitioner,  when  he  has  a  case  of  presumed  disease  of  the  pelvic 
organs  under  investigation.  Do  not  concentrate  all  attention  upon 
this  one  region  of  the  body.  Remember  that  the  fault  may  be  in  dis- 
tant parts ;  that  disease  in  other  organs  may  complicate  disease  in  the 
pelvic  organs.  Do  not,  in  short,  fall  into  the  deplorable  snare  of  be- 
coming a  specialist.  Do  not  imitate  the  error  of  those  physicians  who, 
whilst  rej)udiating  the  idea  of  being  specialists,  and  who,  when  in  the 
presence  of  a  case  marked  by  disorder  of  the  nervous  system,  of  the 
heart,  lungs,  or  abdominal  viscera,  carefully  explore  the  state  of  the 
organs  contained  in  the  skull,  chest,  and  abdomen,  yet  scrupulously 
avoid  exploring  the  not  less  important  organs  contained  in  the  pelvis ; 
and  that  even  although  the  symptoms  point  to  disorder  in  this  region. 

The  great  clinical  rule  should  be :  Interrogate  all  the  functions  ; 
examine  every  organ.  In  this  way  only  can  we  acquire  a  well-founded 
confidence  that  important  disease  is  not  overlooked ;  in  this  way  only 
can  we  rightly  estimate  the  relations  of  symptoms  to  disease,  and  the 
reactions  of  disease  upon  distant  organs,  and  frame  a  rational  plan  of 
treatment. 

A  work  whose  intention  it  is  to  illustrate  the  pathology  of  the  pel- 
vic organs,  must  necessarily  observe  the  limits  of  its  design.  The  art 
of  diagnosis,  therefore,  as  applied  to  the  pelvic  organs,  demands  the 
most  elaborate  description.  But  in  tracing  this  with  almost  exclusive 
care,  as  it  must  be  done  in  a  work  ad  hoe,  it  must  not  be  supposed 
that  general  pathology  or  general  diagnosis  can  ever  be  pretermitted 
in  actual  practice. 


DIAGNOSIS. 


133 


If  it  be  admitted  to  be  necessary  to  investigate  all  the  functions  of 
the  body  in  connection  with  any  presumed  localized  disease,  ci  fortiori 
it  is  necessary,  in  any  case  of  presumed  disease  of  one  of  the  pelvic 
viscera,  to  examine  the  state  of  the  rest,  its  immediate  neighbors. 


Fig.  47. 


Skeleton  diagram  for  recording  alterations  of  size,  position,  and  relations  of  pelvic  and 
abdominal  organs. 


We  must  then  never  neglect  to  inquire  into  the  state  of  the  bladder 
and  rectum.  These  organs  seldom  escape  all  disturbance  when  the 
uterus,  vagina,  or  ovaries  are  affected ;  primary  disease  in  them,  in  its 
turn,  affects  the  uterus,  vagina,  and  ovaries ;  and  not  seldom,  symp- 
toms seemingly  indicative  of  disease  in  the  uterus  or  vagina  are  really 
due  to  disease  in  the  bladder  or  rectum. 

The  order  of  clinical  proceeding,  then,  may  be  laid  down  as  follows  : 
If  a  patient  complain  of  distress  referred  to  the  pelvic  organs,  or 
disorder  of  their  functions,  note  first  the  subjective  symptoms ;  2,  in- 
terrogate the  functions  of  the  nervous,  circulating,  respiratory,  and 


134 


DIAGNOSIS. 


nutritive  organs ;  3,  elicit  the  history  of  the  patient  as  to  her  general 
health,  and  the  antecedents  and  course  of  her  disorders ;  4,  if  the  in- 
dications point  to  disease  in  the  chest  or  abdomen,  subject  the  organs 
contained  in  these  cavities  to  physical  exploration  by  sight,  palpation, 


Skeleton  diagram  for  recording  alterations  of  size,  position,  and  relations  of  abdominal 

and  pelvic  organs. 


percussion,  measurement,  auscultation,  &c. ;  5,  subject  to  physical  ex- 
amination, by  the  methods  hereafter  described,  the  state  of  the  pelvic 
organs,  observing  at  the  time,  or  reserving  for  chemical  and  micro- 
scopical analysis,  the  nature  of  the  local  secretions,  or  of  solid  sub- 
stances expelled ;  6,  when  all  necessary  information  has  been  obtained, 


DIGITAL    TOUCH.  135 

compare  the  symptoms  and  facts  in  tlieir  individual,  relative,  and 
aggregate  significance,  so  as  to  work  out  the  diagnosis  which  shall  de- 
termine treatment. 

In  taking  down  a  case,  it  is  well  to  follow  the  order  indicated  above ; 
and  since  "  word-painting  "  can  hardly  be  so  graphic  as  actual  drawing, 
it  will  be  found  of  great  service  to  attach  to  the  notes  diagrammatic 
memoranda  of  the  position,  shape,  size,  and  other  conditions  of  the 
organs  under  observation.  These  become  extremely  valuable  as  stand- 
ards of  comparison  during  the  future  progress  of  the  case,  and  by 
furnishing  more  intelligible  records  for  other  persons.  To  record  these 
observations,  outline  or  skeleton  diagrams  like  those  represented  in 
Figs.  47,  48,  will  be  extremely  convenient.  The  idea  of  these  will 
be  found  in  one  of  the  grandest  memoirs  on  the  diag-nosis  of  abdomi- 
nal  tumors  ever  published,  that  of  Dr.  Bright,  in  Guy's  Hospital 
Reports.  I  have,  with  the  skilled  assistance  of  Mr.  Denison,  librarian 
to  St.  Thomas's  Hospital,  designed  these  outlines. 

The  physical  exploration  of  the  pelvic  organs  is  conducted  chiefly  by 
the  touch.  The  touch  is  applied  either  directly  by  the  hand,  or  mediately 
through  instruments.  The  touch  is  sometimes  aided  by  sight,  facilitated 
or  not  by  the  speculum  or  other  contrivances  for  bringing  concealed 
parts  into  view.  The  touch  is  also  sometimes  aided  by  the  sense  of 
smell. 

The  touch  takes  precedence  in  importance  and  in  order  of  appli- 
cation of  all  other  methods.  We  may  therefore  usefully  recall  what 
Gooch  said  about  the  "  tactus  eruditus."  "  Some  are  of  opinion  that 
this  art  is  a  blind  tact,  to  be  gained  only  by  practice ;  but  this  is  not 
true ;  the  period  of  my  life  when  I  improved  most  rapidly  in  the  art 
of  deciding  by  examination  cases  of  doubtful  pregnancy  was  that  in 
which  I  gained  clear  and  orderly  notions  of  the  objects  of  examination. 
The  faculty  of  observation  requires  rather  to  be  guided  than  to  be 
sharpened ;  the  finger  soon  gains  the  faculty  of  feeling,  when  the  mind 
has  acquired  the  knowledge  of  what  to  feel  for." 

The  "  tactus  eruditus  "  may  be  defined  as  the  "  educated  touch." 
How  is  the  finger  educated  ?  Greatly  by  practice  in  feeling  the  vari- 
ous conditions  of  form,  size,  consistency,  and  relations  of  the  parts 
upon  which  this  sense  is  to  be  exercised.  But  touch  alone  will  never 
give  perfection  to  the  finger  as  an  instrument  of  diagnosis.  We  must 
be  content,  if  we  would  attain  precision  in  its  use,  to  imitate  the  ex- 
ample of  children,  who,  in  their  earliest  introduction  to  the  study  of 
external  objects,  correct  the  evidence  of  one  sense  by  appealing  to 
another.  When  they  see  a  strange  object  they  try  to  feel  it  also,  and 
even  to  taste  it.  It  is  by  this  tentative  method  of  cross-testing  that 
children  extend  their  knowledge  of  Nature.  We  must  do  the  same. 
We  too  must  correct  touch  by  sight,  and  even  call  the  senses  of  smell- 
ing, taste,  and  hearing  to  our  aid.  Those  physicians  who  boast  of 
possessing  an  "  erudite  tact "  in  vaginal  exploration,  and  who  have 
neglected  the  cross-testing  by  the  eye,  live  in  a  fools'  paradise,  and  must 
necessarily  be  frequently  ^vrong  in  their  appreciation  of  what  they 
touch.  Before  the  speculum  and  the  uterine  sound  were  brought  to 
complete  and  correct  the  information  given  by  the  hands,  a  true  "  edu- 


136  DIGITAL    TOUCH. 

cated  touch  "  could  not  exist.  We  should  ridicule  the  physician  who 
boasted  of  an  "  erudite  ear/'  and  who,  neglecting  the  cross-testing  of 
dissection,  ventured  to  pronounce  dogmatically  upon  the  existence  and 
characters  of  vegetations  upon  the  valves  of  the  heart.  So  must  we 
ridicule  the  pretensions  of  those  who,  relying  upon  their  ignorant  touch 
alone,  venture  to  express  an  absolute  opinion  as  to  the  presence  or 
absence  of  uterine  disease.  Still  more  shall  we  be  justified  in  ridi- 
culing those  who  venture  to  utter  absolute  opinions  upon  a  given  case, 
or  upon  general  questions  of  ovarian  and  uterine  pathology,  without 
so  much  as  using  even  their  fingers.  Their  position  is  simply  that  of 
men  who  pretend  to  know  what  they  have  never  taken  the  pains  to 
learn. 

It  is  only,  then,  by  an  honest  course  of  pathological  study  and  the 
painstaking  education  of  all  our  senses,  separately  and  conjointly,  that 
we  can  gain  the  true  "tactus  eruditis,"  "The  mind,  in  short,  must," 
as  Gooch  says,  "first  acquire  the  knowledge  of  what  to  feel  for." 

It  is  with  the  hope  of  aiding  the  student  in  acquiring  this  knowl- 
edge that  the  preceding  condensed  estimate  or  analysis  of  the  signifi- 
cance of  the  most  ordinary  symptoms  and  characters  of  ovarian  and 
uterine  disease  has  been  worked  out.  Manual  examination,  or  exami- 
nation by  touch,  embraces  the  following  modes  of  exploration:  In 
some,  one  or  both  hands  only  are  used ;  in  some,  the  hand  is  aided  by 
the  sound  or  other  instrument. 

1.  Simple  vaginal  touch,  by  one  finger. 

2.  Ahdomino-vaginal. — The  vaginal  touch  is  aided  by  abdominal 
palpation  with  the  other  hand. 

3.  Simple  I'ectal  touch. 

4.  Recto-ahdominal. — The  finger  in  the  rectum  is  aided  by  abdomi- 
nal palpation.  This  mode  is  often  useful  in  determining  the  size  and 
relations  of  the  uterus,  the  complication  with  uterine  or  extra-uterine 
tumors,  or  the  existence  of  the  uterus  in  vaginal  atresia. 

5.  Recto-vaginal. 

6.  Urethro-vaginal. — The  finger  in  the  vagina  is  aided  by  the  sound 
in  the  urethra. 

7.  Urethro-rectal. — The  finger  in  the  rectum  is  aided  by  the  sound 
in  the  urethra;  indispensable  in  investigating  cases  of  vaginal  atresia. 

8.  Simple  abdominal  palpation  and  percussion. 

9.  Uterine  exploration  by  the  sound, 

10.  Utero-abdominal. — The  sound  in  utero  is  aided  by  abdominal 
palpation. 

11.  Utero-rectal. — The  sound  in  the  uterus  is  aided  by  rectal  touch. 

12.  Examination  by  Speculum. — Here  the  sight  is  the  main  source  of 
information. 

13.  Examination  of  the  secretions,  discharges,  or  substances  expelled. 

Exploration  by  the  Hands. 

Examination  by  the  hand  should  always  precede  the  use  of  instru- 
ments. Because — 1st.  In  many  cases  the  information  gained  by  the 
hands  is  sufficient.     2d.  In  some  cases,  notably  in  cancer,  in  which 


DIGITAL    TOUCH.  137 

sufficient  information  can  be  gained  by  the  hands,  instruments  may  do 
positive  harm. 

The  Mode  of  Making  a  Digital  Examination. 

The  patient  is  placed  either  in  the  lateral  or  dorsal  decubitus.  Each 
position  has  its  advantages.  In  making  a  first  exploration  for  diagno- 
sis, it  is  most  convenient  to  place  her  first  on  her  left  side,  the  knees 
drawn  up,  the  head  and  shoulders  directed  obliquely  across  the  couch, 
on  a  level,  or  nearly  so,  with  the  nates,  and  the  nates  brought  near  the 
edge  of  the  couch.  This  affords  perfect  facility  for  digital  touch,  also, 
for  the  sound ;  and  often  for  the  specuhim.  If  the  patient  lies  on  her  left 
side,  the  surgeon  will  find  it  best  to  use  his  left  hand,  for  then  his  right 
hand  is  conveniently  disposed  for  palpation  above  the  pubes,  and  to 
examine  in  concert  with  the  finger  of  the  left  hand  in  the  vagina. 
If  he  can  only  touch  with  his  right  finger,  he  must  cross  his  left  hand 
awkwardly  over  his  right  to  get  at  the  abdomen.  It  would  be  better 
in  this  case  to  place  the  patient  on  her  right  side,  when  things  will  be 
disposed  conveniently  for  the  right-handed  surgeon.  But  the  obstetric 
surgeon,  like  his  ophthalmic  brother,  ought  to  be  ambidexter,  and  should 
sedulously  cultivate  the  equal  use  of  both  hands. 

Supposing  the  patient  lies  on  her  left  side,  the  usual  obstetric  position, 
the  surgeon  having  anointed  his  left  index  with  cold  cream,  olive  oil, 
glycerin,  or  soap,  arranges  the  bed-clothes  or  dress  with  his  right  hand. 
To  lessen  risk  of  infection,  it  is  well  to  use  carbolized  oil.  The  radial 
edge  of  the  left  hand  is  then  directed  between  the  nates,  and  determines 
the  relation  of  the  parts  by  feeling  the  lower  end  of  the  sacrum  and 
coccyx  and  anus;  the  finger  then  passing  along  the  raphe  of  the  perin- 
eum, comes  necessarily  to  the  edge  of  this  structure  at  the  posterior 
commissure  of  the  labia,  and  therefore  falls  surely  between  the  labia ; 
the  pulp  of  the  finger  is  made  to  enter  at  this  spot,  and  its  further 
progress  is  made  by  pressing  the  back  of  the  finger  against  the  distensi- 
ble perineum  and  onwards,  following  the  curve  of  the  sacrum.  The 
reasons  for  this  mode  of  proceeding  are  to  save  the  patient  the  annoy- 
ance of  touching  the  sensitive  structures  at  the  pubes,  and  to  get  at 
once  between  the  labia,  which  it  is  not  always  easy  to  do,  if  the  finger 
be  directed  more  forwards.  It  is  also  much  more  easy  in  this  way  to 
follow  the  curve  of  the  vao-ina.  To  reach  the  os  uteri,  Avhich  often  lies 
high  up  under  the  promontory  of  the  sacrum,  it  is  commonly  necessary 
to  press  the  perineum  well  back.  The  os  uteri  is  found,  then,  by 
making  the  finger  feel  its  way  all  along  the  posterior  wall  of  the  vagina 
to  its  roof,  until  the  cervix  is  reached.  It  first  takes  note  of  the  size, 
shape,  firmness,  and  character  of  surface  as  to  smoothness  or  roughness, 
of  the  vaginal-portion  of  the  cervix ;  of  the  character  of  the  os  externum 
as  to  patency  or  closure,  of  its  form,  whether  a  fissure  or  round.  Having 
made  these  observations,  the  finger  next  takes  note  of  the  condition  of 
the  supra-vaginal-portion  of  the  neck  and  of  the  body  of  the  uterus. 

Feeling  all  round  the  vaginal-portion,  pressing  the  finger  lightly  into 
the  fundus  of  the  vagina,  in  some  portion  of  the  circumference,  the  re- 
sistance due  to  the  solid  cervix  or  body  will  be  felt.     Following  this. 


138  EXAMINATION     BY    RECTUM    AND     BLADDER. 

the  cervix  is  traced  by  continuity  into  the  body.  If  the  uterus  is  in 
normal  position,  the  body  is  felt  in  front  of  the  cervix  through  the 
upper  and  anterior  wall  of  the  vagina.  Two  other  points  may  now  be 
studied  :  the  bulk,  the  sensitiveness  and  mobility  of  the  uterus.  The 
bulk  is  estimated  by  poising  the  cervix  uteri  on  the  tip  of  the  finger, 
whilst  the  hand  is  pressed  in  above  the  symphysis  pubis,  until  the  solid 
body  of  the  fundus  uteri  is  felt.  Thus,  the  uterus  is  caught  in  its  ex- 
treme length  between  the  two  hands,  and  allowance  being  made  for  the 
thickness  of  the  abdominal  wall,  a  fair  idea  is  obtained  of  its  length 
and  bulk.  The  necessary  pressure  will  determine  the  sensitiveness  of 
the  uterus ;  and  the  poising  of  it  on  the  finger,  alternating  with  depres- 
sion on  the  fundus,  brings  out  the  degree  of  mobility. 

If  the  uterus  is  in  reclination,  the  solid  resistance  of  cervix  and  body 
is  felt  through  the  vaginal  roof  behind  the  cervix.  Again,  by  com- 
bined abdominal  palpation,  the  body  is  caught  between  the  two  hands, 
not  in  its  long  axis,  for  the  fundus  lies  under  the  sacral  promontory, 
but  across  its  body.  The  diagnosis  is  verified  by  bringing  the  examin- 
ing finger  in  front  of  the  cervix ;  and  then  when  abdominal  palpation 
is  resorted  to,  the  hands  approaching  each  other,  find  no  intervening 
body,  i.  e.,  no  uterus  between  them. 

The  finger  next  explores,  by  aid  of  abdominal  palpation,  the  lateral 
regions  of  the  pelvis.  In  this  way,  if  there  is  deposit  in  the  broad 
ligament,  distension  of  the  Fallopian  tubes,  or  enlarged  or  prolapsed 
ovary,  the  abnormal  condition  may  be  made  out. 

The  Digital  Reetal  Touch. 

The  lateral  position  of  the  jjatient  is  still  the  best  for  the  examination 
by  the  rectum.  The  forefinger,  lubricated,  is  passed  into  the  rectum, 
and  exploring  as  it  goes  the  anterior  wall,  the  uterus  is  felt  through  it. 
Commonly,  the  vaginal-portion  is  easily  made  out.  If  the  uterus  is 
strongly  anteverted,  so  that  the  os  is  thrown  backwards,  this  part  will 
project  into  thg  rectum.  This  position  will  account  for  the  pain  some- 
times suffered  at  stool,  when  the  cervix  uteri  is  inflamed  and  enlarged. 
One  of  the  greatest  advantages,  however,  gained  by  rectal  touch,  is  the 
greater  reach  it  gives  one  over  the  body  of  the  uterus.  If  the  uterus 
be  retroverted  or  retroflected,  the  finger  may  usually  reach  the  very 
fundus,  and  thus  take  a  very  accurate  estimate  of  its  bulk,  form,  posi- 
tion, and  sensitiveness.  The  ovaries,  again,  which  lie  a  little  behind 
the  uterus,  may,  in  some  of  their  abnormal  conditions,  often  be  explored 
with  precision  by  the  rectum.  In  the  case  of  some  uterine  tumors  and 
retro-uterine  effusions,  as  hsematocele,  or  peri-uterine  effusions,  exami- 
nation by  rectum  supplements  vaginal  touch,  giving  often  even  more 
valuable  results.  Combined  with  abdominal  palpation,  rectal  touch 
determines  with  great  accuracy  the  bulk  of  the  uterus.  It  can  often  be 
commanded  more  completely  in  this  way  than  by  vaginal  touch. 

Examination  by  the  Bladder. 

It  is  possible  and  sometimes  desirable  to  explore  the  bladder  by  the 
finger  in  the  urethra.     This  canal  in  the  female  is  short  and  very  dis- 


THE    USE    OF    THE    SOUND. 


139 


tensible.  It  may  be  dilated  very  quickly  by  Weiss's  urethral  dilator. 
But  in  the  majority  of  instances,  mediate  exploration  by  the  catheter 
or  uterine  sound  supplies  the  information  that  is  sought. 

The  exploration  of  the  abdomen  by  palpation  and  percussion  is,  of 
course,  best  conducted  with  the  patient  in  the  dorsal  decubitus ;  and 
this  position  is  often  also  the  best  for  the  combined  vaginal  touch  and 
abdominal  palpation.  The  uterus  in  this  decubitus  is  more  easily 
grasped  and  pressed  down  into  the  pelvic  cavity  into  contact  with  the 
finger  in  the  vagina. 

Further  information  is  gained  by  the  sound.  This  is  virtually  a 
lengthened  finger.  It  extends  the  sense  of  touch  beyond  the  point 
which  the  finger  can  reach.  If  there  be  sufficient  indication  to  use  it, 
it  should  be  introduced  before  the  finger  which  has  been  making  the 
observations  already  described  is  withdrawn,  as  it  is  desirable  to  avoid 
the  necessity  of  having  to  repeat  the  vaginal  touch. 


Fig.  49. 


Designed  to  illustrate  diagnosis  of  early  pregnancy. 

B,  bladder,    r,  rectum,    u,  gravid  uterus  in  anteversion.    o,  os  uteri  tilted  up,  and  stretching  the 

anterior  vaginal  wall  from  o  to  v,  making  this  part  tense  and  elastic. 

Before  taking  up  the  sound,  one  precaution  is  imperative.  Be  satis- 
fied that  the  patient  is  not  pregnant.  We  may  acquire  reasonable  as- 
surance of  this  negative  if,  by  combined  vaginal  touch  and  abdominal 
palpation,  we  find  the  uterus  not  exceeding  the  normal  bulk,  and  the 


140        "  THE    USE    OF    THE    SOUND. 

OS  uteri  hard  and  small.  If,  on  the  other  hand,  we  feel  the  os  uteri 
soft,  tilted  far  back  under  the  promontory  of  the  sacrum ;  if  we  feel 
what  I  have  elsewhere  described  as  "  anterior  vaginal  roof-stretching," 
and  the  bulk  of  the  uterus  increased,  the  presumption  of  pregnancy  is 
great.  Then,  do  not  take  up  the  sound.  Another  rule  is  useful.  Never 
use  the  sound  unless  you  have  trustworthy  evidence  that  the  patient 
has  fairly  menstruated  within  the  preceding  fortnight. 

As  this  rule  in  practice  is  exceedingly  important,  I  introduce  a  spe- 
cial illustration  in  order  to  draw  attention  to  the  physical  signs  which 
afford  presumption  of  early  pregnancy.  (Fig.  49.) 

The  Mode  of  Using  the  Uterine  Sound. 

The  patient  still  lies  on  her  left  side.  The  examining  finger  on  the 
OS  uteri  serves  as  a  guide.  The  sound,  held  with  its  concavity  forward, 
is  carried  along  close  to  the  examining  finger  to  the  os,  into  which  it  is  . 
introduced.  When  it  has  passed  an  inch  or  so,  an  obstruction  is  com- 
monly met;  this  is  the  isthmus,  or  os  uteri  internum.  At  this  point 
the  direction  of  the  cervico-uterine  canal  changes ;  and  a  corresponding 
change  must  be  given  to  the  direction  of  the  point  of  the  sound.  When 
the  axis  of  the  uterus  is  normal,  the  canal  curves  gently  forwards,  so 
that  by  carrying  the  handle  of  the  sound  lightly  backwards  the  point 
will  follow  this  curve.  In  giving  the  direction  to  the  sound  we  are 
guided  by  the  information  gained  by  the  digital  touch.  The  body  of 
the  uterus  has  been  felt  in  front  of  the  cervix.  As  the  point  of  the 
sound  passes  on,  the  finger  on  the  os  uteri  takes  note  of  the  extent  to 
which  it  passes,  and  when  it  feels  the  elbow  or  projection  which  marks 
off  two  and  a  half  inches  from  the  point,  on  a  level  with  the  os  exter- 
num, a  sense  of  resistance  is  communicated  to  the  touch.  The  point 
has  reached  the  fundus  of  -the  uterus,  usually  the  most  sensitive  part, 
and  the  patient  will  commonly  complain  of  pain  unless  the  utmost  gen- 
tleness is  used.  The  introduction  of  the  uterine  sound  resembles  the 
introduction  of  the  vesical  sound  or  catheter  in  the  male  urethra.  It 
requires  the  like  delicacy  of  touch ;  the  instrument  is  made  to  feel  its 
way  rather  than  to  be  propelled  by  force.  When  the  sound  has  touched 
the  fundus,  by  imparting  light  movement  to  the  handle  backwards  and 
forwards,  we  ascertain  more  clearly  the  mobility  of  the  organ,  its  rela- 
tion to  neighboring  parts,  and  especially  if  the  form  or  bulk  of  the 
uterus  is  altered  by  fibroid  or  other  tumor  in  its  walls  or  outside.  Whilst 
the  sound  is  in  situ  supporting  the  uterus,  the  hand  outside  depressed 
above  the  pubes  readily  feels  the  fundus,  and  this  pressure  is  commu- 
nicated through  the  sound  to  the  hand  which  holds  it.  By  this  com- 
bined manipulation  also  a  closer  idea  is  formed  of  the  size,  form,  and 
relations  of  the  organ. 

The  variations  in  the  mode  of  using  the  sound  required  by  different 
morbid  conditions  will  be  described  in  the  appropriate  places.  It  will 
be  sufficient  to  add  in  this  place  a  brief  description  of  the  mode  of 
using  it  in  retroversion  or  retroflexion  of  the  uterus.  If  there  be  re- 
troflexion, the  finger  feels  behind  the  vaginal-portion  the  angle  of 
flexion,  and  then  the  body  of  the  uterus.     To  get  the  sound  into  the 


THE    USE    OF    THE    SOUND. 


141 


Fig.  50. 


down-bent  body,  its  curve  must  be  increased,  and  when  the  point  has 
reached  the  os  internum,  the  curve  must  be  reversed;  that  is,  the  con- 
cavity must  be  turned  backwards  to  follow  the  curve  of  the  uterus. 
The  manoeuvre  by  which  this  is  accomplished  resembles  the  foitr  de 
maitre,  by  which  the  male  sound  is  made  to  enter  the  bladder  after 
reaching  the  pubic  arch.  The  point  remains  nearly  stationary,  merely 
turning  on  its  axis,  as  the  handle  is  made  to  describe  a  large  radius. 
Unless  this  be  neatly  done,  the  point  is  apt  to 
slip  out  of  the  cervix,  and  by  describing  a  large 
radius  to  cause  pain.  The  principle  of  this 
manoeuvre  is  made  manifest  by  the  following 
experiment.  Lay  the  sound  on  a  sheet  of 
paper,  and  trace  its  outline  on  the  paper  (Fig. 
50).  Then  keeping  the  point  fixed  by  a  finger, 
give  a  semi-rotation  to  the  handle  so  as  to  re- 
verse the  concavity  of  the  curved  end.  It  will 
be  seen  that  the  uterine  end  simply  turns  upon 
its  axis  without  changing  its  position.  The 
sweep  of  the  handle  is  done  with  the  minimum 
of  force ;  it  is  rather  suffered  to  turn  by  its  own 
weight  than  made  to  do  so  by  force.  When 
reversed,  the  point  of  the  sound  is  made  to 
pass  the  isthmus  by  a  double  consentane- 
ous manoeuvre ;  the  guiding  finger  runs  up  the 
posterior  wall  of  the  cervix,  and  lifts  up  the 
body  of  the  uterus,  straightening  it  a  little  so 
as  to  bring  the  extreme  curve  of  the  uterus 
more  into  agreement  with  that  of  the  sound; 
at  the  same  time  the  handle  of  the  sound  is  car- 
ried forward  under  the  arch  of  the  pubes,  so  as 
to  make  the  point  take  the  direction  of  the 
uterine  canal.     When  the  sound  has  passed  as  ^'^  f^om  c  describes  a  large  ra- 

/>  •,        m  "j.       •!!  11  1      J    dius  in  reversal.    B  is  a  fixed 

lar  as  its  elbow,  it  will  commonly  have  reached      •  .  ^    ■     .^         ■    ^  ^.■ 

'  ,      •'  .  point  during  the   semi-rotation 

the  fundus,     ihe  next  object  is  to  ascertain  the  of  the  instrument,  and  the  end 

mobility  of  the    fundus,  and    to  restore  it  to  its    a  performs  a  very  small  curve 

natural  place.     To  do  this  the  concavity  of  the  ^"  the  uterine  cavity,  if  a  b  be 

-.J-  .  -,  1  •  1         straight  it  will  simply   rotate, 

sound  must  be  again  reversed ;    and   again  the  and  a  a  win  coincide. 
same  manoeuvre  must  be  practiced  as   before 

passing  the  os  internum.  The  handle  is  made  to  describe  a  still  larger 
radius  from  before  backwards,  so  as  to  make  the  point  and  the  intra- 
uterine end  rotate  upon  its  axis.  The  effect  of  this  will  be  to  lift  up 
the  fundus  a  little.  To  bring  it  forward  to  its  proper  position  of  mod- 
erate anteversion,  the  handle  is  carried  straight  backwards.  We  can 
then  feel  the  fundus  supported  on  the  sound  by  abdominal  palpation 
above  the  pubes.  Sometimes,  after  clearing  the  os  externum,  the  knob  is 
arrested  before  it  has  reached  the  os  internum.  The  reason  of  this  will 
be  understood  by  looking  at  the  structure  of  the  cervical  canal.  The  knob 
is  liable  to  get  caught  in  one  of  the  crypts  or  furrows  formed  between 
the  ridges  of  the  arbor  vitse.  This  hitching  is  likely  to  happen  when 
the  knob  is  too  small ;  a  larger  one  will  ride  over  the  pits.  But  even 
with  a  well-chosen  sound  the  accident  may  happen  if  the  patient  has 


Showing  the  reversal  of  the 
sound  in  utero. 

B  corresponds  to  the  os  exter- 
num uteri.    The  handle  extend- 


142  DANGERS    FROM    THE     SOUND. 

long  suffered  from  chronic  cervical  leucorrhoea.  Then  the  mucous 
membrane  is  hypersemic,  swollen,  flabby,  and  the  folds  of  the  arbor 
vitffi  rise  and  overlap,  so  that  the  point  of  the  sound  is  easily  caught,  as 
it  were,  in  a  pocket. 

Some  remarkable  accidents  prove  the  necessity  of  exerting  the  utmost 
care  and  delicacy  of  touch  in  using  the  sound.  The  point  of  the  in- 
strument has  actually  perforated  the  fundus  of  the  uterus.  Two  such 
cases  were  observed  by  Schroeder.  In  both  the  sound  went  without 
force  sixteen  to  seventeen  centimetres  deep,  and  its  knob  Avas  felt 
through  the  thin  abdominal  walls.  Both  were  puerperal  women.  No 
bleeding,  pain,  or  other  bad  symptom  followed.  Professor  E.  Martin 
relates  a  case^  in  which  the  perforation  was  verified  by  autopsy.  Mr. 
Lawson  Tait  relates^  that  Sir  James  Simpson  was  well  aware  of  this 
accident,  and  regarded  it  as  of  no  consequence.  Mr.  Tait  refers  to  two 
cases  under  his  own  observation,  in  one  of  which  he  believed  there  was 
a  fistulous  tract  through  the  fundus.  Dr.  Matthews  Duncan  suggests 
that  the  sound  may  have  run  along  an  unduly  patent  Fallopian  tube. 
I  believe  this  is  quite  possible,  although  Hoening  denies  that  it  is  so.  In 
some  of  the  cases  in  which  the  sound  thus  perforated  the  uterus,  notably 
in  the  two  puerperal  cases  of  Schroeder,  it  is  probable  that  the  uterine 
tissue  was  abnormally  soft.  However  this  may  be,  it  must  be  borne 
in  mind  that  the  sound  roughly  used  may  wound  the  uterus,  and  even 
perforate  it.  I  am  unable  to  look  upon  the  accident  as  of  little  impor- 
tance. The  most  careful  and  judicious  use  of  the  sound  is  sometimes 
attended  and  followed  by  intense  pain.  Metritis  has  occurred ;  and  this 
even  when  there  was  no  reason  to  infer  that  the  wall  had  been  perfora- 
ted. That  fatal  accidents  have  occurred  from  the  use  of  the  sound  can 
hardly  be  doubtful.  I  repeat,  then,  the  injunction  to  avoid  anything 
like  force  in  introducing  the  sound.  It  is  a  question  of  skill,  not  of 
strength.  If  there  be  any  obstacle  to  the  progress  of  the  instrument, 
it  must  be  either  evaded  or  turned,  or  the  attempt  to  pass  it  should  be 
given  up. 

Some  physicians  are  in  so  great  dread  of  accidents  from  the  uterine 
sound,  that  they  condemn  it  altogether.  This  is  unreasonable.  Tlie 
surgeon  does  not  abandon  the  male  sound  or  catheter  because  inexpert 
people  make  false  passages. 

The  danger  just  described  is  avoided  by  using  a  flexible  bougie  in- 
stead of  the  metal  sound.  This  instrument  Dr.  Henry  Bennet  prefers 
also,  from  its  taking  the  form  of  the  uterine  canal,  and  gauging  the 
calibre  of  the  isthmus.  These  are  advantages  not  to  be  disregarded  in 
some  cases.  Where  the  canal  is  very  much  distorted  by  fibroid  tumors, 
it  is  sometimes  possible  for  a  moderately  firm  flexible  bougie  to  worm 
its  way  along  the  tortuous  passage  where  a  rigid  sound  could  not  travel. 
It  is,  however,  open  to  the  objection  that  the  point  being  caught,  the 
stem  will  double. up,  and  thus,  perhaps,  convey  a  false  impression  as  to 
the  distance  it  has  penetrated.  The  flexible  bougie,  if  not  provided 
with  a  knob  at  the  end  a  little  larger  than  the  stem  itself,  will  become 
more  likely  to  be  caught  in  a  cervical  crypt  than  the  metallic  sound. 

'  NcigUTigen  und  Beugungen  der  Gebarmutter.  ^  Lancet,  1871. 


USE    OF    THE    SPECULUM.  143 

Occasionally  the  sound  is  used  through  the  speculum  ;  but  as  a  rule 
this  is  a  mistake.  When  this  is  done,  we  sacrifice  the  aid  which  the 
finger  gives  in  guiding  the  sound,  and  facilitating  its  passage  into  the 
body  of  the  uterus  by  tilting  up  the  body  so  as  to  lessen  any  abnormal 
curve  or  angulation.  And  when  the  uterus  is  much  bent,  it  is  impos- 
sible to  make  the  sound  follow  the  flexion  Mdthout  imparting  a  corre- 
sponding, perhaps  painful,  inclination  to  the  speculum.  Moreover, 
when  the  sound  is  passed  through  the  speculum,  we  lose  much  of  the 
information  which  the  sense  of  touch  imparts. 

One  use,  however,  the  sound  possesses  in  conjunction  with  the  specu- 
lum. It  serves  to  depress  out  of  the  field  of  vision  projecting  folds  of 
vagina,  to  bring  the  os  uteri  more  fairly  into  the  axis  of  the  speculum, 
and  by  passing  the  point  a  little  way  into  the  os,  and  pressing  upon 
one  or  other  lip,  we  may  expose  a  considerable  surface  of  the  cervical 
canal. 

Before  using  the  speculum,  we  have  to  consider  the  means  of  illumi- 
nation. Daylight  is  preferable,  and  the  line  of  light  should  be  hori- 
zontal or  at  a  slight  angle  above  the  horizon ;  the  foot  of  the  couch  or 
bed,  therefore,  should  be  opposite  a  window.  If  a  Fergusson's  silvered 
speculum  be  used,  even  a  dull  light  will  commonly  be  sufficiently  re- 
flected and  focussed  to  give  a  good  view  at  the  field.  But  even  well- 
polished  metal  valvular  specula  are  not  so  well  calculated  for  success 
when  the  light  is  bad.  When  the  valves  are  expanded  they  diverge, 
and  reflection  and  focussing  are  almost  lost.  It  may  then  become  con- 
venient to  concentrate  light  by  a  mirror  or  convex  lens.  A  slightly 
concave  mirror  may  be  so  adjusted  as  to  throw  a  stream  of  reflected 
light  down  the  speculum ;  or  the  light  may  be  collected  into  a  focus  by 
a  convex  lens.  The  mirror  or  lens  may  be  supported  on  a  quaquaversal 
jointed  rod  attached  to  the  couch.  When  daylight  cannot  be  had,  a 
gas-lamp,  or  even  a  candle  may  be  used.  In  the  consulting-room  a 
movable-  gas-lamp  fed  by  a  flexible  tube  is  very  convenient ;  to  such 
a  lamp  a  reflector  might  be  adjusted  to  throw  the  light  into  the  specu- 
lum and  screen  the  surgeon's  eyes. 

I  have  seen  and  tried  a  mirror  which  was  attached  to  the  speculum ; 
I  found  it  more  convenient  to  use  the  mirror  separated. 

The  Mode  of  Introdueing  the  Tubidar  Speeidum. 

As  a  general  rule  the  dorsal  position  is  the  best;  but  it  is  a  necessary 
condition  that  the  bed  or  couch  upon  which  the  patient  reclines  be  firm 
in  the  centre,  so  as  to  obviate  sinking  of  the  nates  in  a  hollow.  To 
maintain  the  nates  at  a  proper  elevation  for  the  admission  of  a  good 
stream  of  light,  striking  horizontally  from  an  opposite  window,  or  at 
most  at  an  angle  of  45°  from  the  horizon,  it  is  also  essential  to  keep 
the  shoulders  and  head  of  the  patient  only  slightly  raised  above  the 
level  of  the  nates.  A  proper  position  of  the  patient  saves  her  from 
unnecessary  annoyance,  and  makes  all  the  diflerence  between  success 
and  failure  to  the  surgeon  in  carrying  out  the  examination. 

The  patient  takes  then  the  dorsal  position,  as  described,  as  near  the 
edge  of  the  couch  or  bed  as  possible. 


144  USE     OF    THE    SPECULUM. 

The  surgeon,  standing  or  kneeling  at  the  side  holding  the  speculum 
lubricated  and  warmed  in  one  hand,  explores  with  the  index  of  the 
other  hand  to  determine  the  exact  position  of  the  cervix  uteri,  the  object 
being,  of  course,  to  get  this  part  in  the  centre  of  the  field  of  the  specu- 
lum. Having  settled  this  j)oint,  he  draws  the  finger  back  to  the  vulva, 
and  brings  up  another  finger  to  hold  open  the  labia;  the  speculum, 
guided  by  these  fingers,  is  then  passed  into  the  vulva  by  getting  the 
end  well  over  the  perineal  border  first;  then,  before  pushing  the  instru- 
ment onwards,  its  end  is  pressed  backwards  so  as  to  depress  the  perineum. 
This  manoeuvre  carries  the  instrument  away  from  the  pubic  arch,  M^here 
it  might  cause  pain  by  jamming  the  soft  parts  against  the  bones,  and 
directs  it  towards  the  hollow  of  the  sacrum  in  the  direction  of  the  axis 
of  the  pelvis.  The  further  direction  of  the  instrument  is  governed  by 
the  idea  which  was  gained  of  the  position  of  the  os  uteri  by  the  explor- 
ing finger.  When  fully  introduced,  if  the  os  should  not  be  found  in 
the  field,  the  instrument  must  be  withdrawn  a  little  way,  and  the  end 
shifted  so  as  to  bring  the  cervix  within  the  field. 

Then  note  is  taken  of  the  aspect  of  the  part,  and  of  the  character  of 
the  discharge.  The  surface  is  often  bathed  with  secretion  so  that  it 
cannot  be  well  seen,  and  the  secretion,  moreover,  would  interfere  with 
the  application  of  remedies.  This  is  removed  by  a  small  pledget  of  cot- 
ton-wool carried  by  the  speculum-forceps. 

When  visiting  a  patient  at  her  own  home  it  is  often  most  convenient 
to  examine  in  the  lateral  position.  The  bed  or  the  source  of  the  light 
may  render  a  satisfactory  examination  in  the  dorsal  decubitus  impos- 
sible. The  patient  then  is  placed  on  her  left  side  on  the  right  side  of 
the  bed,  the  nates  being  drawn  well  up  to  the  edge,  the  knees  slightly 
drawn  up,  and  the  head  and  shoulders  bent  forward  towards  the  mid- 
dle of  the  bed  and  laid  low,  so  as  to  keep  the  nates  high.  Unless  all 
this  be  done,  great  difficulty  will  be  experienced  in  getting  a  direct 
line  of  light,  as  well  as  in  introducting  the  speculum.  The  patient  in 
position,  exploration  is  made  with  the  left  index,  and  the  speculum  is 
inserted  with  the  same  precaution  as  in  the  dorsal  position.  An  ad- 
vantage attending  the  lateral  position  is,  that  artifical  light  is  more 
easily  made  to  serve  where  sufficient  daylight  cannot  be  had.  A  candle 
— a  short  bit  of  wax  taper  is  the  most  handy — can  be  so  held  as  to 
throw  its  light  well  in  the  line  of  the  speculum,  whilst  this  is  held  by 
the  left  hand. 

The  Introduction  of  Sims' s  Speculum. 

The  facility  of  introduction  of  Sims's  speculum  is  one  of  its  recom- 
mendations (Fig.  33).  The  patient  lying  in  the  semi-prone  position  on 
her  left  side,  the  right  leg  is  made  to  cross  in  front  of  the  left ;  this 
brings  the  vulva  well  within  manipulation,  and  makes  it  the  highest 
point  of  the  vaginal  canal.  The  effect  of  this  is,  that  by  placing  the 
uterus  at  a  lower  level,  the  intestines  fall  away  from  the  roof  of  the 
pelvis,  and  the  uterus  tends  to  gravitate  with  them.  Then  when  the 
speculum  is  in  situ,  the  cervix  uteri  is  drawn  forward  out  of  the  hollow 
of  the  sacrum  in  front  of  the  speculum,  and  the  line  of  light  being 


USE    OF    THE    SPECULUM.  145 

at  a  slight  angle  above  the  horizon,  flows  well  down  to  the  cervix  at 
the  bottom.  This  direction  is  also  the  most  convenient  for  therapeu- 
tical manipulation. 

The  mode  of  passing  the  instrument  is  easy.  The  exploring  finger 
determines  the  position  of  the  cervix  uteri,  and  the  capacity  of  the 
vagina  and  vulva.  The  larger  or  smaller  blade  is  selected  accordingly, 
and  then  holding  open  the  vulva  with  one  or  two  fingers,  the  end  of 
the  blade  is  slipped  in  as  near  the  perineum  as  possible,  first  with  the 
width  of  the  spoon  in  a  line  with  the  vulvar  fissure,  and  then,  as  soon 
as  the  end  has  fairly  entered,  the  instrument  is  rotated  so  as  to  bring 
the  back  of  the  spoon  against  the  perineum ;  the  guiding  finger  in  the 
vagina  then,  aided  by  gentle  pressure  on  the  handle  by  the  other  hand, 
carries  the  point  of  the  blade  along  the  posterior  wall  of  the  vagina  to 
its  place  behind  the  cervix.  When  in  situ,  in  order  to  bring  the  cervix 
into  view  it  is  necessary  to  hold  back  the  instrument  firmly  against  the 
perineum,  which  being  distensible  and  yielding  permits  the  curved 
vagina  to  become  straight,  and  thus  the  cervix  to  be  seen.  Sometimes 
when  the  vagina  is  large  and  lax,  the  anterior  wall  will  bulge  up  against 
the  speculum,  and  however  much  the  perineum  may  be  retracted,  the 
cervix  cannot  be  seen,  until  either  by  the  finger,  the  handle  of  the 
sound,  or  a  retractor  made  like  a  tongue-depressor,  the  anterior  wall  of 
the  vagina  is  pressed  up  against  the  pubes.  We  then  get  virtually  an 
inferior  kind  of  Neugebauer.  Sims  further  recommends  the  use  of  a 
fine  hook  (see  Fig.  39)  to  seize  the  vaginal-portion,  to  pull  it  up  into 
sight,  and  to  fix  during  the  application  of  remedies  to  the  surface  or  to 
the  interior  of  the  uterine  cavities.  This  hook,  it  is  said,  causes  little 
pain,  and  the  flow  of  a  few  drops  of  blood.  But  it  appears  to  me  that, 
although  very  convenient  in  some  cases,  it  may  be  dispensed  with  as 
an  habitual  aid  in  examination  and  treatment. 

Introduction  of  Neugebauer^ s  Speculum. 

The  passage  of  the  first  blade  is  made  exactly  in  the  same  way  as 
Sims's  speculum  (Fig.  33).  The  patient  lying  in  the  semiprone  posi- 
tion on  her  left  side,  the  surgeon  takes  the  larger  blade  in  his  left  hand, 
whilst  one  fino-er  of  the  rig-ht  hand  introduced  through  the  vulva  feels 
for  the  OS  uteri ;  this  finger  serving  for  a  guide,  the  end  of  the  blade  is 
slipped  in  over  the  perineum  in  close  approximation  to  the  finger,  and 
carried  along  it  so  as  to  get  behind  the  os  uteri.  If  this  direction  is 
followed,  there  will  be  no  hitch  against  a  fold  of  the  vagina.  When 
the  blade  has  passed  in,  the  handle  is  held  well  back  so  as  to  depress 
the  perineum.  An  assistant  then  raises  the  right  knee  so  as  to  enable 
the  surgeon  to  introduce  the  second  blade,  which  being  a  degree  smaller 
than  the  first,  fits  into  it  as  in  a  groove.  The  uterine  end  is  adapted 
inside  the  handle-end  of  'No.  1,  held  firmly  with  the  left  hand,  and  is 
then  made  to  slide  down  in  No.  1  until  the  handles  of  the  two  blades 
are  on  the  same  level.  Then  the  two  handles  being  brought  forward, 
the  two  blades  work  as  bent  levers,  upon  the  angle  of  junction  of 
handle  and  blade,  which  serves  as  a  hinge  or  fulcrum;  the  uterine  ends 

10 


146  THE    OVARIES:     M  EN  STEU  ATION. 

thus  diverge  like  two  valves,  stretching  the  roof  of  the  vagina,  and 
giving  an  excellent  view  of  the  vaginal-portion  (see  Fig.  34). 

The  w^ithdrawal  of  the  instrument  is  very  simple.  The  two  blades 
must  be  treated  as  one  whole.  The  handles  are  allowed  to  fall  back, 
which  brings  the  uterine  ends  of  the  blades  together.  The  gentlest 
traction  then  upon  one  or  both  blades  will  bring  the  instrument  out, 
the  contraction  of  the  vagina  helping  to  expel  it. 


CHAPTER  Xyil. 

THE  PATHOLOGY  OF  THE   OVARIES. 
THE  HISTORY  OF  MENSTRUATION  AND  ITS  DISORDERS. 

The  relation  of  the  ovary  to  the  function  of  menstruation  has  been 
referred  to  when  describing  the  anatomy  of  this  organ.  A  few  further 
observations  upon  this  subject  are  necessary  to  serve  as  an  introduction 
to  the  study  of  the  disorders  of  menstruation,  and  of  the  organic 
diseases  of  the  ovary. 

The  most  important  laws  in  this  application  to  pathology  are  illus- 
trated in  the  following  facts  : 

The  catamenia,  the  name  given  by  Aristotle  to  the  monthly  discharge 
from  the  uterus,  indicates  the  periodicity  of  menstruation.  In  all  lan- 
guages, and  throughout  all  ages,  names  indicating  this  periodicity  have 
been  adopted.     The  "menses,"  "les  mois,"  "les  regies,"  are  examples. 

But  this  character  of  periodicity,  so  striking,  was  not  traced  to  its 
true  cause  or  connection  until  the  present  century.  It  was  scarcely 
suspected,  certainly  not  demonstrated,  that  the  periodical  monthly  flow 
was  dependent  upon  another  periodical  act,  the  ripening  of  ova.  Dr. 
Power,  a  man  of  singular  sagacity,  seems  to  have  been  the  first  to  seize 
upon  this  great  fundamental  fact.  In  1821  he  distinctly  enunciated 
the  theory.  Girdwood,  in  1826,  brought  new  observations  in  proof  of 
this  theory.  It  was,  however,  warmly  disputed  in  this  country,  es- 
pecially by  Dr.  Robert  Lee,  whose  authority  probably  retarded  its 
general  acceptance,  so  that  it  was  not  until  Negricr,^  in  1831,  working 
as  it  appears  independently,  proved  by  adequate  researches  and  ana- 
tomical preparations,  that  the  outward  and  visible  periodical  discharge 
of  menstruation  was  the  expression,  the  consequence  of  an  internal  and 

1  "  Recueil  de  faits  pour  servir  a  I'Histoire  des  Ovaires."     Angers,  1858. 


MENSTRUATION,  147 

hidden,  but  superior  function.  Gendrin,  Paterson,  Raciborski,  Bischoif, 
and  others  followed  with  fresh  proofs  which  established  the  theory 
against  all  disputes.  The  preparations  of  Coste,  preserved  in  the  Col- 
lege of  France,  show  the  following  points :  A  Graafian  vesicle,  the 
ripening  of  vvhich  always  coincides  with  the  turgescence  of  the  genital 
organs,  pursues  the  course  of  its  development  during  the  various  phases 
of  menstruation ;  and,  according  as  the  circumstances  are  more  or  less 
favorable,  it  may  burst  at  the  commencement,  or  towards  the  end,  or 
at  any  moment  of  this  periodical  discharge.  In  a  woman  who  died 
on  the  first  day  of  the  appearance  of  the  menses,  the  ovarian  vesicle 
was  manifestly  ruptured.  In  another,  who  died  four  or  five  days  after 
the  cessation  of  the  menses,  the  right  ovary  presented  a  vesicle  still 
intact,  but  so  distended  that  the  slightest  pressure  made  it  burst. 
Lastly,  in  a  young  virgin,  who  died  fifteen  days  after  menstruation, 
there  was  no  recent  trace  of  a  yellow  body,  and  it  could  not  be  doubted 
that  the  Graafian  vesicle  had  been  arrested  in  its  development.  The 
subjects  of  these  observations  had  all  died  a  violent  death  in  the  midst 
of  health. 

Thus,  we  may  conclude  that  at  each  menstruation  a  Graafian  vesicle 
assumes  a  marked  preponderance  over  the  rest,  arrives  spontaneously 
at  maturity,  and,  generally,  bursts  at  an  indeterminate  moment  of  this 
period,  in  order  to  expel  the  ovum  it  contains ;  but,  nevertheless,  in 
certain  cases  this  vesicle  may  also  remain  stationary,  or  be  totally  ab- 
sorbed. The  double  phenomenon  is  analogous  to  what  is  observed  in 
mammifera,  during  the  rut. 

Roederer^  observed  that  the  ovaries  grew  towards  the  epoch  of  com- 
mencing menstrual  life  and  became  atrophied  at  the  menopause.  He 
distinctly  found  that  the  atrophy  of  the  ovaries  was  more  marked  and 
more  closely  associated  with  the  cessation  of  menstruation  than  was 
the  atrophy  of  the  uterus. 

If  the  ovaries  are  absent  or  ill-developed,  girls  do  not  menstruate, 
the  breasts  are  flaccid  or  defective  in  development,  the  characters  of 
womanhood  do  not  become  manifest.  This  may  be  said  to  be  experi- 
mentally proved  by  the  celebrated  case  of  Pott.  A  girl  aged  23,  of 
good  constitution,  went  to  Bartholomew's  Hospital,  in  consequence  of 
two  tumors  situated  in  the  groins,  which  had  for  several  months  caused 
her  so  much  pain  that  she  could  not  attend  to  her  work.  She  was 
healthy,  and  menstruated  regularly.  The  tumors  -were  soft,  uneven, 
easily  movable,  and  lay  externally  to  the  tendinous  apertures  of  the 
inferior  abdominal  wall.  Pott  determined  to  remove  them.  After 
dividing  the  skin,  a  thin  membranous  sac  was  found,  in  which  a  body 
was  inclosed  that  was  taken  to  be  the  ovary.  It  w^as  removed,  and  the 
same  operation  was  repeated  on  the  other  side.  From  this  time  forth 
she  never  menstruated,  her  breasts  fell  away,  and  the  muscular  system 
became  developed  as  in  man. 

If,  then,  the  ovaries  are  extirpated  or  become  atrophied,  menstru- 
ation does  not  reappear.  Raciborski  says  the  menses  may  be  a  little 
postponed,  but  that  this  does  not  always  prevent  the  follicles  from  pur- 

1  "  Icones  Uteri  Humani,"  1779. 


148  OVULATION. 

suing  their  regular  course,  and  from  accomplishing  dehiscence.  He 
has  seen  on  ovaries  of  young  girls  one  or  two  cicatrices,  although  they 
had  never  menstruated.  Thus  also  women  who  had  never  menstruated 
have  conceived.     But  these  cases  are  very  rare. 

The  first  dehiscence  corresponds  with  the  first  appearance  of  the 
menses. 

Whitehead  relates  cases  of  conception  in  persons  who  had  never 
menstruated ;  and  conception  during  lactation  whilst  menstruation  is 
suspended  is  not  uncommon. 

Dr.  Ritchie^  also  adduced  evidence  to  show  that  ovulation  may  go 
on  although  there  is  no  menstrual  discharge.  Negative  observations, 
then,  as  to  the  menstrual  flow  do  not  prove  that  ovulation  is  also  sus- 
pended ;  and  ovulation  is  obviously  the  condition  of  impregnation. 

Menstruation,  then,  is  the  natural  epoch  for  the  escape  of  ova ;  and, 
consequently,  it  is  the  most  favorable  to  conception.  But  a  question 
of  great  interest  is  attached  to  this  conclusion.  Do  the  epochs  of 
ripening  and  of  the  natural  fall  of  the  ova  always  and  of  necessity  re- 
turn in  a  regular  manner  ?  That  is,  are  there  not  other  influences 
besides  the  rut  and  menstruation,  capable  of  hastening  the  epochs  of 
maturation  and  fall  of  the  ova  ?  This  must  be  answered  in  the  affirm- 
ative. Thus,  the  pigeon  in  its  wild  state  lays  eggs  only  once  or  twice 
a  year,  whilst  in  our  pigeon-houses  it  lays  seven  or  eight  times.  Hens, 
whose  eggs  are  taken  away  from  them  to  prevent  their  sitting,  lay  al- 
most every  day  for  eight  months  in  the  year.  The  rabbit,  which,  in  a 
state  of  liberty,  has  only  one  or  two  litters  a  year,  has  perhaps  seven  when 
its  young  are  taken  away  at  a  suitable  time.  The  period  of  maturation, 
then,  far  from  being  immutable,  appears  to  depend  upon  certain  con- 
ditions which  may  accelerate  or  retard  it.  Similar  conditions  exert 
similar  influences  in  women ;  and  there  is  reason  to  believe  that  sexual 
intercourse  may  hasten  the  maturation  of  ova,  and  especially  their 
escape  from  the  ovary. 

Admitting,  however,  as  we  must,  the  occasional  operation  of  dis- 
turbing circumstances,  the  general  law  is  that  these  phenomena  are 
reproduced  periodically ;  and  that  during  the  periods  when  they  are 
manifested  certain  signs  attend,  which  in  the  aggregate  bear  the  name 
of  menstruation.  Consequently  the  ripening  of  ova,  and  most  fre- 
quently their  dehiscence,  are  revealed  outwardly  by  the  appearance  of 
the  catamenia. 

We  may  now  conveniently  study  this  function  from  a  clinical  point 
of  view,  fixing  our  attention  mainly  upon  those  phenomena  which  are 
open  to  direct  observation.  Pouchet^  has  distinguished  the  different 
phases  of  menstruation  with  great  precision,  by  defining  its  difterent 
periods,  and  by  comparing,  by  help  of  the  microscope,  the  discharges 
attending  it  with  those  of  the  intermenstrual  period. 

Characters  of  the  Menstrual  Discharge. — The  first  sign  of  the  advent 
of  the  menses  is  the  manifestation  of  a  particular  odor  imparted  to  the 
mucus  secreted  by  the  sexual  organs.     The  second  sign  is  a  change  of 

1  "  Ovulation  during  Amenorrhcea."      Ed.  M.  &  S.  J.,  1845. 

2  "  Theorio  Positive  de  I'Ovulation  Spontanec."     Paris,  1847. 


MENSTRUATION.  149 

color  of  the  utero-vaginal  mucus ;  at  first,  dull  white,  it  becomes  brown- 
ish ;  some  blood-disks,  mingled  with  numerous  mucous  globules  and 
fragments  of  epithelium,  floating  in  the  liquid,  account  for  this  change 
of  color.  The  first  period  lasts  one  or  two  days.  Sometimes  it  imme- 
diately precedes  the  flow  of  blood ;  sometimes  the  mucus  becomes  nor- 
mal again ;  then,  after  an  interval  of  a  day,  blood,  almost  pure,  sud- 
denly escapes  from  the  vulva. 

The  flow  of  ruddy  blood  constitutes  the  second  period.  The  fluid 
secreted  is  composed  of  blood,  not  cliifering  from  arterial,  mixed  with 
vaginal  mucus.  By  the  microscope  we  find  mucous  globules  in  various 
stages  of  development,  thin  fragments  of  transparent  epithelial  scales, 
mixed  with  innumerable  blood-disks.  This  flow  usually  ceases  in  three 
or  four  days ;  but  in  some  women  it  is  continued  for  seven  or  eight 
days,  without  obvious  departure  from  the  physiological  condition. 

The  menstrual  blood  diifers  from  pure  blood,  in  not  coagulating ; 
that  is,  under  ordinary  conditions.  Dr.  Whitehead  explained  this  by 
showing  that  the  vaginal  mucus  has  an  acid  reaction,  and  that  contact 
of  the  blood  with  this  acid  prevented  its  coagulation.  Donn6  also  says 
that  menstrual  blood  is  acid,  containing  phosphoric  and  lactic  acids. 
Mandl,  however,  showed  that  the  smallest  quantity  of  pus  or  mucus 
stopped  blood  from  coagulating.  Now,  the  menstrual  discharge  is  blood 
mixed  with  mucus.  That  admixture  with  mucus  accounts  for  the  flu- 
idity of  the  menstrual  discharge  may  be  admitted ;  and  so  long  as  the 
quantity  of  blood  is  within  normal  bounds,  the  proportion  of  mucus 
supplied  is  sufficient ;  but  if  the  blood  be  in  excess,  and  if  it  be  re- 
tained a  little  while,  it  will  coagulate.  Thus  it  is  that  in  menorrhagia 
clots  are  frequently  passed.  Clotting  in  the  cavity  of  the  uterus  causes 
pain  and  contractions. 

The  quantity  of  the  blood  exhaled  becoming  less  and  less  abundant, 
its  color  changes  from  red  to  brown,  the  proportion  of  blood-disks 
diminishes,  whilst  that  of  the  mucous  elements  increases  ;  at  length  the 
mucus  itself  becomes  thinner.  It  is  especially  at  the  end  of  this  period 
that  the  Graafian  vesicles  may  burst  spontaneously. 

When  the  menstrual  discharge  has  ceased,  the  internal  surface  of  the 
uterus,  and  especially  that  of  the  vagina,  casts  off  numerous  epithelial 
scales,  at  first  nearly  entire,  but  soon  reduced  to  fragments  of  more  or 
less  tenuity.  These  scales  or  debris  constitute  during  the  first  inter- 
menstrual days  the  greater  part  of  the  solid  elements  contained  in  the 
excretions  of  the  vulva ;  the  rest  is  composed  of  a  variable  number  of 
mucous  globules.  Virchow  insists  that  the  detachment  of  the  uterine 
mucous  membrane  is  more  complete  than  is  generally  supposed,  and 
that  in  normal  menstrual  blood  heaps  of  cells  are  often  met  with,  which 
by  their  structure  reveal  their  origin  in  the  uterine  glands. 

Just  as  in  women  who  have  already  menstruated,  the  menses  are  pre- 
ceded by  a  modification  in  the  quantity  and  color  of  the  normal  sexual 
secretions ;  so  in  the  young  girl,  who,  not  having  yet  menstruated,  has 
arrived  at  puberty,  the  menstrual  hemorrhage  is  often  preceded  by  a 
serous  whitish  or  brownish  discharge.  This  discharge  may  anticipate 
by  several  months  the  appearance  of  the  blood,  and  may  recur  several 
times  before  this  makes  its  appearance.     Often  also  after  the  first  san- 


150  MENSTRUATION. 

guineous  discharge  in  a  young  girl,  several  months  may  intervene  be- 
fore the  menses  set  in.  The  like  phenomena  are  repeated  at  the  disap- 
pearance of  the  menstrual  discharge,  when  the  privilege  of  fecundity  is 
lost. 

This  similarity  of  the  phenomena  attending  the  first  advent  and  the 
climacteric  cessation  of  menstruation  is  especially  deserving  of  note. 
There  is,  1.  Irregularity  as  to  periodicity,  2.  Occasional  excess  of 
blood  loss,  amounting  to  hemorrhage.  3.  Alternate  enlargement  and 
subsidence  of  the  abdomen.     4.  Pain  and  induration  of  the  breasts. 

The  quantity  of  blood  discharged  at  each  epoch  varies  in  different 
women,  and  in  the  same  woman  under  different  circumstances.  It 
usually  ranges  from  three  to  four  ounces.  Generally  it  is  more  abun- 
dant in  women  living  in  luxury.  And,  according  to  Burdach  and 
Brierre  de  Boismont,'^  it  is  more  copious  in  hot  than  in  cold  countries. 
Our  countrywomen  in  India  are  more  subject  to  menorrhagia  than  when 
in  England. 

A  vulgar  error  still  prevails  that  the  menstrual  blood  has  fetid  or 
even  poisonous  projjerties.  This  is  only  true  under  the  conditions  of 
retention,  of  uncleanliness,  or  admixture  with  the  products  of  disease. 

The  Source  of  the  Menstrual  Blood. — Haller  was  aware  that  it  came 
from  the  womb.  Observations  in  point  have  been  made  under  two 
different  conditions  ;  that  is,  in  the  living  and  in  the  dead.  First,  the 
uterus,  examined  in  cases  of  complete  prolapsus,  and  where  there  is  no 
prolapsus,  by  the  speculum,  blood  is  seen  to  issue  from  the  os  uteri ; 
and  in  cases  where  the  uterus  is  turned  inside  out  the  menstrual  blood 
is  seen  directly  oozing  from  the  mucous  membrane  of  the  body  of  the 
uterus.  Secondly,  on  examining  the  bodies  of  women  who  have  died 
during  menstruation,  Coste  and  others,  myself  among  them,  have  seen 
the  vascular  apparatus  of  the  uterus  developed  and  injected  in  an  ex- 
traordinary manner.  The  vascular  structure  of  the  mucous  membrane, 
in  particular,  forms  on  the  surface,  under  the  fine  layer  of  epithelium 
which  covers  it,  a  beautiful  network,  each  mesh  of  which  incloses  a 
glandular  tube.  This  vascular  reticulation  is  so  marked  and  rich  that 
it  gives  a  more  or  less  deep  violet  tint  to  the  inner  surface  of  the  uterus. 
According  to  all  probability,  it  is  through  the  walls  of  these  ramuscules 
that  the  menstrual  blood  oozes.  "  In  one  case,"  says  Coste,  "  death 
took  place  exactly  at  the  moment  when  the  blood  began  to  ooze  through 
the  engorged  vessels.  There  were  seen  in  the  course  of  these  vessels 
an  innumerable  multitude  of  small  red  points,  as  if  the  mucous  mem- 
brane had  been  pricked  with  a  fine  needle,  each  prick  giving  issue  to  a 
minute  droplet  of  blood.  Here  and  there,  under  the  epithelium,  were 
small  ecchymoses,  indicating  that  the  hemorrhage,  suspended  by  death, 
had  not  yet  made  a  complete  escape.  In  other  women,  the  phenomenon 
being  more  advanced,  the  cavity  of  the  uterus  was  found  filled  with  red 
fluid  blood,  about  to  escape  by  the  neck." 

Some  experiments  made  by  Matthews  Duncan,  to  determine  "  the 
power  of  the  uterus  to  resist  a  bursting  pressure  "  (1868),  seem  to  me 

1  "  De  la  Menstruation  dans  ses  Rapports  Physiologique  et  Patliologiqiie,"  Paris, 
1842. 


MEjSiSTEUATION.  151 

to  find  application  here.  Air  was  forcibly  driven  by  a  pump  against 
a  piece  of  uterus  stretched  over  a  tube.  "  It  was  curious,"  he  says, 
"  to  observe  the  permeability  of  all  the  unruptured  tissues  to  this 
fluid."  The  experiments  being  performed  under  water,  the  air  bubbled 
up,  or  effervesced  from  the  peritoneal  surface  by  innumerable  minute 
points.  In  all  probability  the  mucous  membrane  of  the  uterus  and  the 
delicate  coats  of  the  bloodvessels  offer  even  less  resistance  under  the 
hydraulic  pressure  to  which  they  are  subjected  by  the  increased  turges- 
cence  attending  menstruation.  This  oozing  from  a  free  surface  is  a  pro- 
tection against  extravasation  in  deep  structures,  which  could  not  fail 
to  be  injurious. 

This  intense  vascular  engorgement  involves  the  ovaries  and  Fallo- 
pian tubes  as  well  as  the  uterus ;  and  there  is  no  doubt  that  blood  is 
effused  from  the  whole  tract  of  the  tubo-uterine  mucous  membrane. 
Dr.  Letheby  [PMl.  Trans.,  1852)  describes  the  microscopical  characters 
of  the  menstrual  fluid  found  in  the  tubes  in  the  bodies  of  two  young 
women  who  died  whilst  menstruating. 

Periodicity. — The  typical  periodicity  is  every  twenty-eight  days.  In 
many  women  the  return  is  exact  to  the  day.  There  is,  however,  a 
range  of  variation  in  different  women ;  in  some  the  interval  from  the 
commencement  of  one  menstruation  to  the  return  of  the  next  is  less  than 
twenty-eight  days,  in  others  more  rarely  exceeding  thirty  days ;  that 
is,  if  strict  periodicity  be  observed.  In  women  whose  intervals  vary, 
being  sometimes  more,  sometimes  less  than  twenty-eight  days,  some 
pathological  element  probably  exists. 

The  Age  at  which  Menstruation  Begins. — In  temperate  climates,  be- 
tween the  ages  of  thirteen  and  fifteen,  concurrently  with  the  appear- 
ance of  other  signs  of  puberty,  as  the  growth  of  hair  on  the  genital 
parts,  and  the  swelling  of  the  breasts,  the  menses  begin  to  flow.  Here, 
again,  there  are  considerable  variations.  Cases  are  recorded  of  men- 
struation beginning  at  ten,  and  even  as  early  as  seven  or  six  years  of 
age.  These  must  be  regarded  as  instances  of  quite  exceptional  pre- 
cocity. Retardation  is  more  common;  cases  are  not  infrequent  of  the 
first  appearance,  or  at  least,  of  the  fair  establishment  of  menstruation,  at 
sixteen  or  seventeen.  In  these  there  is  mostly  some  pathological  con- 
dition. Since  the  outbreak  of  this  function  of  the  uterus  is  a  symptom 
or  consequence  of  the  entry  into  active  function  of  the  ovary,  it  may 
be  concluded  that  whatever  causes  hasten  or  retard  the  evolution  or 
ripening  of  the  ova,  will  have  a  corresponding  effect  upon  men- 
struation. 

Hence  luxurious  living  and  libidinous  excitement,  tend  to  forestall 
the  ordinary  period,  whilst  the  contrary  conditions  of  hard  living  and 
freedom  from  sexual  emotion  tend  to  postpone  it. 

Climate  has  been  said  to  have  a  powerful  influence.  The  observa- 
tions of  Brierre  de  Boismont  and  others  seem  to  have  pi'oved  that  the 
advent  of  menstruation  is  decidedly  earlier  in  hot  climates  than  in  cold. 
And  common  observation  proves  that,  tested  by  their  physical  and  in- 
tellectual characters,  girls  pass  into  womanhood  at  a  somewhat  later 
age  in  cold  and  temperate  climates;  whilst  the  women  in  hot  climates 
fall  at  an  earlier  age  into  sexual  decrepitude. 


152  MENSTRUATION. 

In  Siarn,  according  to  Dr.  Campbell  [Edin.  Med.  Journ.,  1862), 
some  girls  arrive  at  puberty  at  twelve,  but  the  more  usual  ages  are 
fourteen,  fifteen,  and  sixteen.  Dr.  Goodeve  gives  about  twelve  as  the 
mean,  and  Dr.  Leith,  of  Bombay,  twelve  and  a  half.  But  of  a  series 
of  cases  tabulated  by  him,  the  largest  number  menstruated  after 
fourteen. 

The  influence  of  cold  is  further  seen  in  the  character  of  the  men- 
struation. Thus,  Dr.  McDiarmid,  surgeon  to  Sir  John  Ross's  Arctic 
Expedition,  says  that  amongst  the  Esquimaux,  menstruation  is  often 
delayed  until  the  twenty -third  year,  and  then  only  appears  scantily 
during  the  summer.  I  also  know  women  of  feeble  sexual  development 
Avho  menstruate  in  the  summer  only. 

Probably,  race  may  have  as  much  to  do  with  the  period  of  advent  of 
menstruation  as  climate.  Observation  of  the  Jews,  who  are  to  be 
found  in  almost  every  climate,. might  determine  this  question,  and  thus 
enable  us  to  appreciate  more  accurately  the  influence  of  climate.  Is 
the  first  appearance  of  menstruation  amongst  the  Jews  inhabiting  dif- 
ferent countries  uniform  or  not  ? 

The  period  of  disappearance  of  menstruation  is  more  uncertain  than 
that  of  its  commencement.  Usually  about  the  age  of  forty  to  forty- 
five  some  irregularity  begins.  But  the  function  often  continues  with 
complete  regularity  until  forty-five  and  sometimes  fifty,  and  even  be- 
yond. The  instances,  not  infrequent,  in  which  periodical  discharges  of 
blood,  not  distinguished  by  the  subject  from  ordinary  menstruation,  are 
continued  much  beyond  fifty,  may,  with  considerable  confidence,  be 
suspected  to  be  due  to  some  abnormal  condition.  This  is  especially 
true  when  the  issue  of  blood  is  greater  in  quantity  and  lasting  longer 
than  the  subject  had  been  accustomed  to  observe ;  and  the  presumption 
that  some  disease,  local  or  remote,  is  present,  is  very  great  when  profuse 
losses  of  blood,  periodical  or  not,  break  out  after  the  menstruation  has 
ceased  for  some  months. 

If  it  is  difficult  to  determine  the  latest  limit  for  the  persistence  of 
healthy  menstruation,  so  is  it  to  determine  the  earliest  limit.  It  is  a 
popular  belief,  that  if  a  woman  begins  her  menstrual  life  at  an  early 
age,  she  will  cease  to  menstruate  at  an  earlier  ag-e  than  those  wdio  begin 
later.  Another  mode  of  expressing  this  theory  is  to  say  that  the  epoch 
of  menstrual  life,  that  is,  of  active  ovulation,  and  hence,  of  aptitude 
for  conception,  lasts  for  thirty  or  thirty-five  years.  Negrier's  observa- 
tions, however,  seem  to  prove  the  reverse.  He  says  :  "  It  seems  well 
proved  that  the  ovarian  function,  creative  of  germs,  is  prolonged  in  life 
in  direct  ratio  of  the  volume  of  the  ovaries  and  of  the  precocity  of 
ovulation  ;  thus,  the  girl,  nubile  at  twelve,  will  continue  menstruating 
until  fifty,  or  even  fifty-five ;  whilst  the  girl  who  did  not  menstruate 
until  eighteen  or  twenty,  a  fact  which  reveals  feeble  development  and 
small  energy  of  the  organ,  will  cease  to  menstruate  at  forty — an  early 
age."  Considerable  departures  from  this  limit  are  probably  due  to 
some  morbid  disturbing  element ;  and  in  many  cases  the  departures  are 
more  apparent  than  real.  For  example,  at  the  commencement,  although 
no  sanguineous  discharge  may  mark  the  onset  or  establishment  of  men- 
struation for  several  months,  or  a  year  or  two,  there  is  no  doubt  that 


MElSrSTRUATIOJSr.  153 

ovulation,  the  essential  motive  of  menstruation,  goes  on.  This  is  proved 
by  cases  in  which  pregnancy  has  occurred  without  menstruation. 
Whitehead  has  recorded  such  cases.  Dr.  West  relates  the  history  of  a 
lady  who  married  at  twenty,  never  having  menstruated,  but  who  became 
pregnant  immediately.  After  childbearing,  she  menstruated  regularly. 
In  other  cases,  a  leucorrhoeal  discharge,  "  white  menstruation  "  it  might 
be  called,  returns  periodically,  attended  by  the  usual  indications  of 
menstruation.  In  a  third  series  of  cases,  even  the  white  discharge  may 
be  wanting,  and  still  a  sluggish  kind  of  ovulation  may  occur.  This  is 
observed  in  some  forms  of  amenorrhoea. 

At  the  other  end  of  the  history  we  sometimes  find  menstruation 
ceasing  at  a  comparatively  early  age,  that  is,  before  forty,  even  at  thirty- 
seven  or  thirty-six.  These  can  hardly  be  instances  where  the  allotted 
thirty  years  have  run  out,  from  having  begun  prematurely.  Most  fre- 
quently the  explanation  is  that  ovulation,  or  its  exponent,  menstruation, 
has  been  prematurely  arrested  by  some  intercurrent  condition  of  the 
ovaries  or  of  the  uterus.  Sir  James  Simpson  described  a  condition  in 
which  the  ordinary  involution  of  the  uterus  which  follows  delivery, 
seems  to  have  passed  the  physiological  bounds,  and  to  have  proceeded 
to  positive  atrophy,  thus  ushering  in  a  premature  senility.  Whatever 
the  explanation,  I  can  attest  the  fact  that  a  woman  who  has  borne  a 
child  at  thirty -six  or  thirty-seven  has  henceforth  never  menstruated  or 
conceived  again.  In  most  of  these  women  I  have  found  the  uterus 
reduced  below  its  normal  bulk,  and  presenting  the  other  features  of  the 
senile  uterus,  whilst  the  breasts  also,  which  obey  so  closely  the  impulse 
of  the  ovaries,  have  shrunk ;  these  women  are  overtaken  by  an  early 
climacteric. 

In  not  a  few  instances,  however,  the  explanation  of  N^grier  holds 
good,  namely,  that  the  early  cessation  of  menstruation  is  due  to  original 
feeble  ovarian  development.  In  these  women  the  menstrual  excretion 
is  scanty  and  appears  late ;  their  languid  genital  functions  are  exhausted 
long  before  the  normal  epoch. 

In  other  instances  the  premature  failure  is  due  to  the  exhausting  in- 
fluences of  disease. 

The  most  distinct  evidence  that  healthy  menstruation  may  be  pro- 
tracted much  beyond  the  age  of  forty-five  is  drawn  from  the  undoubted 
fact  that  occasional  pregnancy  takes  place  after  that  age. 

Many  cases  of  precocious  menstruation  are  recorded.  In  some,  the 
common  signs  of  puberty  appear  to  have  been  almost  congenital.  These 
cases  form  a  class  distinct  in  some  features  from  the  premature  men- 
struation which  appears  at  from  nine  to  twelve  years  of  age.  In 
infantile  menstruation,  says  Dr.  Harris,  of  Washington  [American 
Journal  of  Obstetrics,  1871),  no  matter  how  young  the  infant  may  be 
when  the  menses  have  made  their  first  appearance,  the  mamrate  are 
found  unusually  developed,  and  the  pubes  shaded  with  hair  ]  the  sub- 
jects have  menstruated  regularly,  have  grown  rapidly,  inclining  to 
obesity,  and  have  not  presented  any  sign  of  weakness ;  it  is  little  de- 
pendent upon  climate ;  there  is  generally  no  marked  precocity  of  mental 
development;  sexual  passion  is  not  marked. 

Sir  Astley  Cooper  narrates  the  history  of  a  child  which  commenced 


154  MENSTRUATION. 

to  menstruate  at  three  years  old,  and  was  last  noticed  by  him  when 
seven  years  and  five  months  old  ;  at  this  early  age  she  had  all  the  ap- 
pearance of  a  thickset  stunted  woman;  she  measured  four  feet  one 
inch,  and  had  so  large  a  pelvis  that  she  could  no  doubt  have  given  birth 
to  a  child.  {Lond.  Med.  and  Phys.  Journ.,  1810.)  Le  Beau  mentions 
a  similar  case  [Annales  d'Hygiene,  vol.  x).  In  the  case  of  infantile 
puberty,  the  ribs  and  pelvis  are  excessively  developed,  and  shortness  of 
stature  results.  Where  menstruation  begins  at  eight  or  afterwards,  the 
growth  of  the  body  is  not  usually  interfered  with. 

That  early  menstruation  depends  upon  early  ovulation  is  further 
proved  by  the  occasional  occurrence  of  very  early  jjregnancy.  Several 
well-authenticated  cases  of  girls  being  mothers  at  thirteen,  or  even 
twelve  years  old,  are  recorded.  Dr.  Roberton  tells  of  a  girl,  working 
in  a  cotton  factory,  who  was  delivered  of  a  full-grown  child  when  only 
a  few  months  advanced  in  her  twelfth  year.  She  had  menstruated  be- 
fore falling  pregnant.  Mr.  Smith,  of  Coventry,  relates  {Record  of 
Obstetric  Medicine,  vol.  i)  the  case  of  a  girl  who  at  twelve  years  and 
seven  months  gave  birth  to  a  full-grown  healthy  child.  She  began  to 
menstruate  at  the  age  of  ten.  Dr.  J.  G.  Wilson  reports  {Edin.  Med. 
Journ.,  1861)  the  case  of  a  girl  who  began  to  menstruate  when  twelve 
years  and  six  months  old  in  January  and  until  April.  She  was  deliv- 
ered of  a  full-grown  child  at  thirteen  years  and  six  months. 

In  several  cases  of  premature  menstruation,  exhaustion  and  death 
have  occurred  (Clifford  Allbutt,  Med.-Chir.  Trans.,  1866).  But  this 
is  not  the  rule. 

Vicarious  or  ectopic  menstruation  occurs  when  hemorrhagic  discharges 
take  place  periodically  from  other  organs  than  the  uterus.  The  oc- 
currence of  this  remarkable  phenomenon  is  evidence  of  the  force  of 
the  periodical  habit.  It  seems  as  if  every  month  a  state  analogous  to 
plethora,  or  an  accumulation  of  blood  arose,  which  must  be  relieved  by 
evacuation.  The  active  physiological  process  going  on  in  the  ovaries 
naturally  determines  the  blood-current  in  especial  force  to  the  pelvic 
organs  ;  hence  the  uterus  is  the  natural  evacuant  organ.  It  is  a  remark 
made  by  Trousseau,  that  all  the  physiological  discharges  of  blood  take 
place  from  mucous  membranes.  A  happy  provision,  for  mucous  mem- 
branes all  lead  to  external  outlets.  If  serous  membranes  were  equally 
liable  to  pour  out  blood,  the  blood  must  be  imprisoned  in  close  sacs, 
and  pressure  and  inflammation  would  constantly  imperil  life.  It  Avill 
generally  happen,  then,  when  the  mucous  membrane  of  the  uterus  is 
not  disposed  to  execute  its  functions,  that  some  other  mucous  mem- 
brane will  supplant  it.  The  most  frequent  seat  of  vicarious  menstrua- 
tion is  the  Schneiderian  membrane.  In  young  people  especially,  epis- 
taxis  is  easily  excited.  There  can  be  no  doubt  that  in  many  cases  it 
is  a  beneficial  safety-valve.  Certainly  menstrual  epistaxis  is  a  quasi- 
physiological  phenomenon,  which  should  be  checked  only  with  great 
circumspection.  In  some  cases  I  have  known  epistaxis  to  accompany 
the  ordinary  menstrual  discharge  from  the  uterus  ;  thus  supplementing, 
not  supplanting  it. 

Various  parts  of  the  alimentary  canal  may  assume  the  work  of  the 
uterus.  The  stomach  is  perhaps  the  most  frequently  called  upon. 
Thus  we  have  menstrual  hoimatemesis. 


VICAEIOUS    MENSTRUATION.  155 

Hcemoptysis  is,  I  believe,  occasionally  a  manifestation  of  vicarious 
menstruation.  The  right  appreciation  of  this  condition  is  obviously  of 
great  importance,  lest  it  be  misinterpreted  as  a  symptom  of  tubercular 
mischief. 

Other  parts  may,  however,  do  similar  duty.  Thus  we  occasionally 
see  hemorrhage  from  the  rectum.  And  towards  middle  age,  when 
haemorrhoids  are  not  uncommon,  these  bleed  more  freely  at  the  men- 
strual periods. 

During  pregnancy,  when  the  uterine  mucous  membrane  is  barred 
against  hemorrhagic  response  to  the  ovarian  excitation,  I  have  several 
times  seen  hsematemesis  occur.  The  natural  disposition  to  vomiting 
which  attends  pregnancy  may  to  some  extent  account  for  the  hemorrhagic 
molimen  being  determined  to  the  stomach.  I  have  notes  of  cases  in  which 
menstrual  hsematemesis  seemed  to  be  hereditary.  In  some  there  is  a 
distinctly  hemorrhagic  diathesis,  as  in  the  following  instance  :  A  young- 
lady,  aged  twenty-four,  had  several  attacks  of  hsematemesis  more  or 
less  profuse,  and  at  last  one  which  was  so  severe  and  protracted  that 
she  made  a  very  narrow  escape  with  her  life.  It  appeared  to  be  con- 
nected with  menstrual  deviation.  She  recovered  fairly ;  but  six  months 
later,  just  when  menstruation  was  due,  having  felt  sick,  and  oppression 
at  the  stomach,  she  vomited  a  small  quantity  of  dark  blood,  the  menses 
appearing  at  the  same  time  scantily.  She  never  suffers  dysmenorrhoea. 
A  sister,  when  sixteen,  who  had  hitherto  menstruated  scantily,  had 
hsematemesis  at  her  periods.  A  brother,  aged  five,  died  of  epistaxis 
after  purpura.  The  father  died  of  epistaxis  at  fifty -six,  caused,  his 
wife  says,  by  intemperance,  which  produced  epilepsy.  Whenever  he 
had  a  fit  he  had  hemorrhage. 

The  conjunctiva  is  another  mucous  membrane  which  evinces  a  par- 
ticular proclivity  to  pour  out  blood  vicariously.  I  have  seen  a  woman 
who  every  month  suffered  profuse  ecchymoses  of  both  eyes,  some  blood 
escaping  from  the  surface,  and  some  being  effused  under  the  conjunc- 
tivae, to  be  gradually  absorbed,  and  passing  through  all  the  stages  of 
ecchymosis  of  the  eye  from  direct  violence. 

Liebreich  has  figured  in  his  magnificent  Ophthalmoscopic  Atlas 
(Plate  VIII,  English  edition,  1870)  an  example  of  retinal  hemorrhage 
after  suppression  of  menstruation.  He  says  he  has  several  times  seen 
the  same  appearances,  and  always  in  women. 

The  iskin  is  not  infrequently  the  seat  of  vicarious  menstrual  hemor- 
rhage. Sometimes  the  blood  appears  in  the  form  of  petechia  or  small 
ecchymoses  on  various  parts  of  the  body,  but  sometimes  it  has  actually 
been  seen  to  ooze  in  droplets  from  the  surface,  forming  a  true  bloody 
sweat. 

There  seems  some  analogy  between  these  cases  and  the  bumps  of 
erythemo.  nodosum,  which  are  not  uncommon  on  the  legs  of  girls  suffer- 
ing from  amenorrhoea. 

In  some  instances  the  blood  is  poured  out  from  a  varicose  ulcer  or 
other  sore.  Dr.  Mason  relates  {Edin.  Med,  Journ.,  1866)  a  case  in 
which  menstruation  began  at  eight,  and  continued  to  recur  until  eleven, 
then  stopped  until  thirteen.  A  large  abrasion  then  formed  in  the  right 
cheek,  suppurating  in  the  centre,  and  inclining  to  bleed  towards  the 


156  MENSTRUATIOIS'. 

circumference.  The  menstruation  was  now  irregular.  After  a  time 
this  place  healed ;  blood  then  oozed  from  the  skin  of  the  face. 

Dr.  Basset  relates  [Presse  Medieale)  a  case  of  a  woman  who  con- 
sulted him  on  account  of  periodical  discharges  of  blood  by  the  nipples. 
Menstruation,  however,  Avas  also  present,  although  scanty.  The  patient 
had  borne  three  children. 

Mr.  d'Andrade  relates  an  interesting  case.^  The  subject  was  a  stout, 
healthy  Parsee  lady,  aged  eighteen.  She  had  menstruated  regularly 
from  thirteen  to  fifteen  and  a  half,  when  the  catamenia  became  first  ir- 
regular, then  ceased,  being  replaced  by  bleeding  at  the  gums  and  nose, 
and  vomiting  of  blood.  Menstruation  returned.  No  pregnancy.  Mr. 
d'Andrade  observed  blood  to  ooze  from  the  healthy  skin  of  the  left 
breast,  and  of  the  right  forearm.  The  blood  exuded  showed  red  and 
white  globules  under  the  microscope.  The  skin-hemorrhage  recurred 
every  month  or  two.     Subsequently  blood  oozed  from  the  forehead. 

The  following  case,^  which  occurred  in  St.  George's  Hospital  in  1872, 
under  the  care  of  Dr.  John  Clarke,  is  so  complete  in  its  history,  and  so 
illustrative  of  several  important  points  in  physiology  and  pathology, 
that  I  am  induced  to  quote  it  at  length : 

"J.  C ,  aged  eighteen,  was  admitted  into  the  hospital  on  May 

30th,  1872.  The  history  of  the  case  is  as  follows  :  Her  family  were 
healthy.  She  was  single,  and  had  never  seen  any  catamenial  dis- 
charge ;  but  for  three  months  before  admission  she  had  from  time  to 
time  suffered  pain  at  the  lower  part  of  the  back  and  between  the 
shoulders.  During  these  attacks  of  pain  she  had  bleeding  from  the 
nose  and  gums,  which  lasted  about  a  week,  and  then  ceased,  returning 
again  after  the  interval  of  one  month.  For  two  or  three  weeks  before 
she  came  into  the  hospital  she  had  had  great  irritability  of  her  skin,  to 
relieve  which  she  had  recourse  to  scratching ;  but  this  gave  rise  to  im- 
mediate bruising  of  the  parts.  For  four  months  past  she  had  complained 
of  pain  in  the  left  side,  accompanied  with  difficulty  of  breathing,  cough, 
and  spitting  of  blood.  She  had  never  had  rheumatic  fever ;  but  about 
five  years  ago  she  suffered  from  chorea. 

"On  admission  she  was  very  ansemic,  the  lips  and  conjunctivae  being 
almost  bloodless.  She  suffered  from  shortness  of  breath,  and  had  fre- 
quent bleedings  from  the  nose,  mouth,  and  skin.  She  said  she  had 
never  menstruated.  There  were  hemorrhagic  spots  on  the  tongue,  in- 
side the  lips,  and  on  the  gums.  Some  of  the  spots  on  the  tongue  Avere 
as  large  as  half  a  split  pea,  and  the  tip  was  so  covered  with  ecchymoses 
that  it  had  the  resemblance  of  a  strawberry.  The  lips  were  cracked, 
and  on  the  inner  side  were  numerous  ecchymosed  spots.  The  surface 
of  the  chest  was  more  or  less  marked  with  these  hemorrhages,  but  here 
some  of  the  spots  could  be  picked  off.  At  the  places  where  scratching 
had  been  practiced  there  were  distinct  bruises.  On  the  legs  and  thighs 
the  spots  had  more  the  character  of  the  hemorrhages  seen  in  purpura. 
In  many  places  the  blood  seemed  to  have  actually  exuded  from  the 
skin,  as  they  could  readily  be  lifted  off;  but  there  was  no  evidence 

'  Trans,  of  Med.  and  Phys.  Soc.  of  Bombay,  1862.  =  Lancet,  1872. 


VICARIOUS    MENSTEUATION".  157 

that  mechanical  means  had  been  employed  to  produce  them.  For  four 
or  five  days  she  had  suffered  from  epistaxis.  On  examining  the  chest, 
a  loud  mitral  murmur,  most  marked  at  the  apex,  was  heard,  the  heart's 
action  being  very  irregular  and  rapid.  The  lungs  were  resonant,  and 
air  freely  entered ;  but  the  breathing  was  rapid  and  labored  even  after 
slight  exertion.  There  was  a  troublesome  cough,  and  occasionally  the 
patient  spat  blood.  There  was  no  vaginal  orifice;  the  small  cavity  rep- 
resenting the  canal  of  the  vagina  ended  in  a  cul-de-sac,  and  was  not 
deep  enough  to  hold  a  teaspoonful  of  fluid.  The  urethra  was  in  the 
middle  of  this  cavity.  The  labia  majoria  were  well  formed,  but  small, 
and  there  was  an  ordinary  amount  of  pubic  hair.  The  space  between 
the  rectum  and  the  urethra  measured  about  half  an  inch.  On  passing 
the  finger  into  the  rectum,  no  uterus  could  be  discovered ;  and,  when  a 
catheter  was  introduced  into  the  bladder,  it  could  be  distinctly  felt 
through  the  anterior  wall  of  the  rectum.  jS'umerous  ecchymoses  were 
present  on  the  inner  side  of  the  labia  majora.  The  patient  was  ordered 
beef  tea,  milk,  and  eggs. 

"  May  31st. — Breathing  easier ;  ecchymoses  still  come  out ;  bleeding 
from  nose  and  gums  about  the  same  as  above.  Ordered  two  drachms 
of  infusion  of  digitalis,  and  twenty  minims  of  tincture  of  perchloride  of 
iron,  to  be  taken  every  four  hours  Avith  some  spirits  of  nitrous  ether. 
At  night  to  have  a  purge  composed  of  ten  grains  of  calomel  and  colo- 
cynth  pill. 

"  June  1st.  Medicine  to  be  discontinued  and  purgatives  to  be  admin- 
istered.    Tlie  patient  complained  in  the  evening  of  feeling  faint. 

"  2d.  Bowels  have  acted  freely ;  epistaxis  much  diminished;  complains 
of  feeling  sick ;  has  vomited.  To  have  some  hydrocyanic  acid  and 
soda  mixture  every  four  hours. 

"  3d.  Spots  gradually  fading ;  bleeding  from  nose  and  gums  nearly 
stopped.     Purgative  medicine  to  be  discontinued. 

"  8th.  Gradually  improving. 

"The  patient  continued  to  improve  till  June  11th,  when  the  breath- 
ing became  much  embarrassed,  and  accompanied  with  severe  palpita- 
tion of  the  heart,  cough,  and  spitting  of  blood,  death  taking  place  at  3 
P.M.,  consciousness  remaining  till  the  last. 

"Autopsy. — Body  well  nourished;  limbs  and  trunk  covered  with 
ecchymoses.  Mammse  fairly  well  developed,  but  nipples  small.  Color 
of  the  hair  light^brown.  Oi\  opening  the  thorax  the  pleurae  were  found 
to  be  spotted  with  ecchymoses.  The  lungs  were  oedematous,  and  gorged 
with  blood.  The  pericardial  cavity  contained  a  small  quantity  of  light- 
red  fluid,  but  the  walls  were  dotted  with  hemorrhagic  spots,  especially 
the  visceral  wall.  The  endocardium  at  the  upper  part  of  the  left  ven- 
tricle w^as  thickened  and  opaque.  The  aortic  valves  were  thick,  puck- 
ered, and  inefficient ;  the  mitral  valve  thickened,  and  so  contracted  that 
the  orifice  would  only  admit  the  tip  of  the  little  finger.  The  muscu- 
lar walls  of  the  right  ventricle  and  left  auricle  much  hypertrophied. 
The  liver,  spleen,  and  kidneys  did  not  present  any  abnormal  appear- 
ance. The  ovaries  were  very  well  developed  and  congested,  and  con- 
tained a  recent  false  corpus  luteum.     The  uterus  was  absent  (evidently 


158  MENSTRUATION. 

congenitally),  only  a  small  nodule  of  fibrous  tissue  being  found  in  the 
folds  of  peritoneum  between  the  rectum  and  the  bladder." 

Here  we  see  exhibited  in  a  striking  manner  the  influence  of  ovula- 
tion upon  the  system.  There  being  no  uterus,  the  menstrual  blood 
sought  outlet  in  almost  every  direction,  and  the  function  failing,  the 
patient  died.  The  case  is  extremely  valuable,  as  showing  that  absence 
of  the  uterus  or  its  imperfect  development  does  not  imply  defective 
development  of  the  ovaries.  Possibly  an  operation  for  the  construction 
of  a  vagina  to  oj^en  a  communication  with  the  rudimentary  uterus 
might  have  been  of  service. 

These  cases  of  vicarious  menstruation  prove  how  intense  is  the  effort 
of  Nature  to  seek  an  outlet  for  blood.  They  seem  to  show  that  the 
tension  of  the  vascular  system  becomes  general  when  the  outlet  by  the 
uterine  mucous  membrane  is  not  free.  Tliis  general  tension  is  illus- 
trated  by  the  frequent  sensation  complained  of  by  sufferers  from  araen- 
orrhoea  and  dysmenorrhoea,  of  "  those  things  flying  to  the  head,"  evi- 
denced by  headache,  vertigo,  and  epistaxis.  These  phenomena  of  vas- 
cular tension  suggest  that  the  rational  treatment  consists  in  diminish- 
ing tension  by  purgatives  and  leeches,  or  by  cupping. 

Two  conditions  in  the  healthy  subject  siispend  menstruation, — Preg- 
nancy and  Lactation.  The  arrest  of  menstruation  is  the  most  familiar 
presumptive  evidence  of  pregnancy.  The  law  is,  that  from  the  moment 
of  conception  menstruation  is  stopped,  and  does  not  return  until  the 
child  is  weaned.  Many  exceptions,  however,  occur.  Some  of  these  are 
apparent  rather  than  real.  When  pregnancy  occurs,  the  lining  mem- 
brane of  the  uterus,  being  wanted  for  the  new  function  of  connecting 
the  impregnated  ovum  with  the  uterus,  undergoes  a  remarkable  change 
of  structure.  If  it  were  now  to  pour  out  blood,  the  relation  of  the 
ovum  to  the  uterus  would  be  disturbed,  and  abortion  would  ensue.  In 
fact,  this  not  seldom  does  occur.  Notwithstanding  the  general  truth 
of  the  theory  of  the  Genesial  Cycle,  so  well  described  by  Tyler  Smith, 
which  expresses  the  law  of  the  successive  domination  of  the  ovaries, 
uterus,  and  breasts  in  the  woman,  it  is  certain  that,  although  during 
pregnancy  and  lactation  the  ovaries  are  comparatively  subdued  or  qui- 
escent, ovulation  occasionally,  if  not  always,  goes  on.  Negrier  and 
Scanzoni  have  especially  insisted  that  pregnancy  does  not  arrest  ovula- 
tion. If  in  the  majority  of  cases  we  miss  the  common  proof  or  expo- 
nent, menstrual  discharge,  yet  the  other  signs  of  ovarian  activity  are 
frequently  present.  There  is  a  monthly  molimen  or  nisus,  marked  by 
greater  turgidity  and  accumulation  of  blood  in  the  pelvic  organs.  Hence 
the  epochs  when  the  return  of  the  menses  is  due  are  those  when  abor- 
tion is  most  likely  to  happen.  The  influence  of  ovulation  is  also  seen 
in  the  later  months  of  gestation,  markedly  when  the  placenta  grows  to 
the  loAver  or  cervical  zone  of  the  uterus.  In  this  case  liemorrhages  are 
apt  to  break  out  at  the  menstrual  epoclis.  And  generally  premature 
labor  is  more  likely  to  occur  at  these  than  at  intermediate  periods. 

But  menstrual  hemorrhage  may  occur,  especially  during  the  first  three 
months  of  gestation,  without  interfering  with  the  relations  of  the  ovum 
to  the  uterus.  This  may  be  explained  in  two  ways :  First,  the  blood 
may  be  poured  out  from  the  free  surface  of  the  decidua  vera  lining  the 


EFFECT    OF    LACTATION.  159 

inferior  zone  of  the  uterus,  and  even  from  the  free  surface  of  the  decidiia 
reflexa.  Secondly,  it  may  exude  from  the  congested  cervical  cavity. 
This  is  especially  likely  to  occur  when  there  is  ulceration  or  abrasion 
of  the  OS  or  cervix,  or  inflammatory  congestion. 

3Iensfruation  during  lactation  is  much  more  frequent  than  during  ges- 
tation. Although,  normally,  the  breasts  are  now  in  the  ascendant,  the 
ovaries  are  not  always  dormant.  Many  women  really  menstruate 
throughout  lactation,  and  not  infrequently,  in  spite  of  suckling,  preg- 
nancy occurs.  In  the  majority,  perhaps,  menstruation  is  in  abeyance 
for  nine,  ten,  eleven,  or  twelve  months  if  suckling  is  kept  up.  Some 
women,  hoping  to  postpone  pregnancy,  go  on  suckling  for  fifteen,  eigh- 
teen, or  even  twenty-four  months.-  Only  a  certain  proportion  succeed 
in  their  object.  After  nine  months  the  ovarian  excitement  usually  be- 
comes too  strong  to  be  subdued  by  the  more  languid  activity  of  the 
breasts,  menstruation  reappears,  the  milk  dries  up,  and  pregnancy  often 
quickly  follows. 

In  other  suckling  w^omen,  however,  the  menstruation  is  chiefly 
apparent.  From  imperfect  involution  of  the  uterus  after  labor,  from 
congestion,  from  abrasions  or  ulcerations  of  the  os  and  cervix  uteri,  or 
from  disorder  of  remote  organs,  discharges  of  blood,  which  may  or 
may  not  be  periodical,  occur.  If  these  irregular  hemorrhages  are 
much  protracted,  excessive  in  quantity,  and  present  marked  deviations 
from  periodicity  in  recurrence,  it  may  be  concluded  that  there  is  a  mor- 
bid factor,  local  or  remote,  wdiich  calls  for  investigation.  In  very  im- 
pressionable or  nervous  women,  the  mere  act  of  applying  the  child  to 
the  breast  will  cause  a  discharge  of  blood  from  the  uterus,  offering  one 
example  of  the  many  of  the  intimate  correlation  between  the  ovaries, 
the  uterus,  and  breasts. 

It  is  convenient  here  to  notice  the  influence  menstruation  exerts 
upon  the  milk.  It  is  generally  believed  that  the  milk  is  injuriously 
affected ;  and  common  observation  shows  that  the  suckling  is  often 
griped,  or  has  diarrhoea,  at  the  nurse's  monthly  periods.  Raciborski, 
indeed,  says  the  milk  is  not  sensibly  altered  in  its  properties ;  it  simply 
appears  to  be  less  rich  in  cream.  I  have,  however,  observed  that  co- 
lostrum-globules were  reproduced  at  every  menstrual  epoch.  And  it 
must  be  borne  in  mind  that  the  activity  of  the  ovaries  renders  the 
nurses  more  susceptible  to  moral  impressions  and  to  emotions.  The 
influence  of  emotion  in  disturbing  the  milk  cannot  be  doubted.  In 
the  contention  for  supremacy  the  ovary  is  pretty  sure  to  win.  If  the 
woman  is  exposed  to  sexual  relations,  active  ovulation  and  menstru- 
ation are  very  likely  to  be  quickly  resumed.  Thus,  in  spite  of  suck- 
ling, impregnation  often  occurs  within  two  or  three  months  of  delivery  ; 
and  not  a  few  women  fall  pregnant  wdthin  six  months  "  wdthout  seeing 
anything  between."  On  the  other 'hand,  women  who  have  become 
widows  before  or  soon  after  delivery,  and  lived  a  single  life  afterwards 
out  of  a  feeling  of  concentrated  affection,  keep  up  lactation  for  eighteen 
months  or  two  years  wdthout  a  return  of  menstruation.  But  this, 
perhaps,  they  could  not  have  done  had  the  ovaries  been  subject  to  the 
excitement  of  married  life. 

As  a  rule,  nursing  women  continue  unfruitful  until  the  activity  of 


160  MENSTEUATIOX. 

the  mammary  secretion  has  remitted,  this  remission  being  shown  by 
the  necessity  of  adding  foreign  substances  to  the  infant's  food. 

We  may  now  attempt  to  trace  the  local  and  constitutional  reactions, 
that  is,  the  symptoms  or  concomitants  of  menstruation.  First,  the  local 
conditions.  There  is  congestion  or  hypersemia  of  all  the  genital  system ; 
ovaries,  uterus,  and  breasts  swell  and  become  turgid.  Scauzoni  had 
an  opportunity  of  directly  observing  this.  In  a  remarkable  case  of 
inguinal  hernia,  the  contents  of  the  sac  included  the  uterus  and  ovaries. 
He  found  these  organs  to  sw^ell  and  become  painful  to  the  touch  at 
every  menstrual  period.  Concej^tion  took  place  twice  whilst  the  uterus 
w^as  in  the  sac  (Beitrage,  1871).  Many  women  are  conscious  of  a  sense 
of  fulness,  weight,  and  pain  in  the  region  of  the  ovaries,  which  points 
to  the  distension  of  these  organs.  Then  there  is  the  evidence  of  post- 
mortem inspection  of  the  ovaries  of  women  dying  during  menstruation, 
W'hich  shows  them  to  be  full  to  the  point  of  bursting  with  blood.  In- 
deed, w^ien  an  ovum  escapes  there  is  an  actual  rent  in  the  capsule  of 
the  ovary ;  in  some  cases  phenomena,  in  a  certain  sense  traumatic,  as 
severe  pain,  a  kind  of  shock,  are  present. 

The  state  of  the  uterus  has  been  partly  described.  The  mucous 
membrane  overgorged,  actually  allows  blood  to  ooze  from  its  surface. 
The  bulk  of  the  uterus  is  increased.  This  may  be  determined  by  its 
greater  weight  as  ascertained  by  touch,  and  by  examination  between 
the  two  hands.     The  vagina  also  is  more  vascular  and  turgid. 

The  breasts  sympathize  with  the  pelvic  molimen.  They  swell 
visibly,  become  firmer,  sometimes  painfully  hard.  This  is  especially 
the  case  at  the  age  when  menstruation  is  being  established.  Under 
the  ovarian  stimulus  the  breasts,  like  the  uterus,  actually  grow ;  they 
assume  their  full  development  or  evolution.  So  great  is  the  activity 
thus  provoked,  that,  occasionally,  this  rapid,  almost  sudden,  action 
passes  the  physiological  boundary ;  the  glands  present  nodular  masses, 
extremely  tender  to  pressure ;  they  may  even  inflame,  and  I  have  seen 
these  phlegmons  form  abscesses  in  the  breasts  of  virgins,  produced 
apparently  under  this  sole  ovarian  excitation.  This  is  in  strict  analogy 
with  the  history  of  the  production  of  phlegmons  in  the  breast  after 
labor.  I  have,  however,  suspected,  in  some  cases,  that  libidinous  ma- 
nipulation of  the  breasts  was  in  some  degree  concerned.  The  forma- 
tion of  abscesses  is,  indeed,  rare ;  but  it  is  not  rare  to  find  at  puberty 
nodular  painful  points  in  the  breasts,  which  give  rise  to  great  anxiety 
as  to  their  real  nature.  Howsoever  rare  and  improbable  cancer  of  the 
breast  may  be  in  young  girls,  it  is  not  always  easy  to  allay  the  appre- 
hension that  it  exists.  Mere  surgical  examination  is  not  always  enough 
to  establish  a  decisive  diagnosis,  affirmative  or  negative.  At  any  rate, 
I  have  known  surgeons  of  great  experience  at  fault  in  these  cases ;  and 
it  was  only  on  further  consultation  that,  in  two  instances,  I  rescued  the 
patients  from  undergoing  needless  amputation  of  the  breast.  In  con- 
sidering these  cases,  then,  we  must  make  great  allow^ance  for  the 
physiological  stimulus,  and  deliberate  well,  calling  Time,  which  solves 
so  many  problems,  into  consultation. 

These  local  conditions  are  usually  well  marked  throughout  menstrual 
life.    But  the  remote  or  induced  phenomena  are  generally  more  strongly 


PHENOMENA    OF    MENSTRUATION.  161 

characterized  at  the  first  appearance  of  the  function.  The  following 
description,  however,  whilst  it  applies  more  strongly  to  the  first  men- 
strual periods,  will  serve,  with  modifications  in  degree,  for  the  subse- 
quent menstrual  history. 

The  vascular  excitement  of  the  genital  organs  cannot  fail  to  affect 
other  parts  of  the  body  and  the  general  system.  The  nervous  centres, 
especially,  feel  and  respond  to  and  sympathize  with  the  altered  condi- 
tion of  the  genital  system. 

In  most  instances,  there  are  prodromata,  forerunning  signs,  the  sig- 
nificance of  which  is  well  known  to  the  subject.  These,  like  the  signs 
which  occur  at  later  stages,  will  vary  in  different  individuals.  In  women 
whose  health  is  good,  whose  organs  are  perfectly  adapted  to  the  easy 
performance  of  their  function,  the  prodromata  are  scarcely  noticed,  and 
all  the  phases  of  menstruation  are  gone  through  with  little  or  no  local 
or  general  disturbance.  In  such  persons  a  slight  sense  of  fulness  in  the 
pelvis,  some  little  perturbation  of  the  circulation,  signs  suggesting 
plethora,  are  speedily  followed  by  the  flow  which  brings  complete  relief. 
All  sense  of  trouble  passes  away  with  a  momentary  lassitude  that  does 
not  compel  to  the  interruption  of  ordinary  duties.  Such  persons  are 
often  more  cheerful  and  animated  at  the  menstrual  periods ;  their  ideas 
flow  more  brightly ;  their  emotions  are  more  kindly. 

But  in  a  very  large  proportion  of  women,  things  do  not  run  so 
smoothly.  In  many  the  function  is  performed  with  more  or  less  diffi- 
culty, and  causes  more  or  less  general  disturbance.  This  may  arise 
from  one  of  two,  or  a  combination  of  the  two  circumstances.  The  sub- 
ject may  be  of  excessively  impressible,  nervous  temperament,  stirred 
too  readily  and  immoderately  by  ordinary  excitation.  Or,  secondly, 
there  may  be  local,  mechanical,  or  other  hindrances  to  the  fulfilment  of 
the  menstrual  acts.  Or  the  two  conditions  may  be  combined.  In  either 
of  these  cases,  not  only  may  the  prodromata  be  severe,  but  the  stage  of 
menstruation  itself  will  be  attended  with  suffering,  and  even  when  the 
function  is  fairly  completed,  distress  will  not  be  altogether  allayed. 

Amongst  the  prodromata  are  pain  in  the  pelvis,  a  sense  of  fulness, 
backache,  pain  especially  in  one  iliac  region,  and  radiating  down  the 
thighs.  The  alimentary  canal  reveals  the  impression  made  upon  the 
ganglionic  centre  by  vomiting  and  diarrhoea.  Lassitude,  to  the  extent 
of  prostration,  seizes  the  patient.  The  mind  is  always  more  or  less 
disturbed.  Perception,  or  at  least  the  faculty  of  rightly  interpreting 
perceptions,  is  disordered.  Excitement  to  the  point  of  passing  delirium 
is  not  uncommon.  Irritability  of  temper,  disposition  to  distort  the 
most  ordinary  and  best  meaning  acts  or  words  of  surrounding  persons, 
afflict  the  patient,  who  is  conscious  of  her  unreason,  and  perplex  her 
friends,  until  they  have  learned  to  understand  these  recurring  outbursts. 
Despondency  to  the  verge  of  melancholy,  violence  to  the  verge  of 
mania,  impulse  ungovernable  to  the  verge  of  monomania,  false  ideas, 
distorted  judgment  to  the  verge  of  delusion,  and  sometimes  overstepping 
the  boundary,  render  the  sufferer  for  a  time  really  irresponsible. 
Lunatic  asylums  offer  numerous  examples  of  comparative  abeyance  of 
the  usual  manifestations  of  insanity  during  the  intermenstrual  periods, 
and  of  their  exacerbation  ^vhen  the  catamenia  return.     Not  even  the 

11 


162  MENSTRUATION. 

best  educated  women  are  all  free  from  these  mental  disorders.  Indeed, 
the  more  preponderant  the  nervous  element,  the  greater  is  the  liability 
to  the  invasion.  Women  of  coarser  mould,  who  labor  with  their  hands, 
especially  in  outdoor  occupations,  are  far  less  subject  to  these  nervous 
complications.  If  they  are  less  frequently  observed ;  if  they  less  fre- 
quently drive  refined  women  to  acts  of  flagrant  extravagance,  it  is 
because  education  lends  strength  to  the  innate  sense  of  decorum,  and 
enables  them  to  control  their  dangerous  thoughts,  or  to  conceal  them 
until  they  have  passed  away. 

In  other  cases  the  ovarian  excitation  evokes  a  fit  of  what  is  called 
hysteria.  This,  too,  is  sometimes  to  a  great  extent  kept  in  subjection 
by  a  determined  will ;  but  when  once  this  habit  has  grown,  the  attack 
is  usually  irrepressible.  I,  as  well  as  other  physicians,  have  observed 
cases  in  which  a  fit  of  eclampsia  has  ushered  in  menstruation.  In  some 
of  these  there  existed  an  hereditary  or  other  predisposition  to  this  form 
of  convulsion ;  but  still  the  exciting  action  of  ovulation  was  clear. 
Sometimes  stupor  or  lethargy  is  the  prominent  symptom,  but  this  is 
more  frequent  as  a  result  of  hysteria  or  eclampsia.  Associated  occa- 
sionally with  hysteria,  or  independent  of  it,  erotic  passion  is  the  promi- 
nent symptom.  When  this  occurs,  the  lapse  into  insanity  is  often  near. 
After  committing  the  grossest  excesses,  which  may  for  a  time  be  attrib- 
uted to  moral  depravity,  the  disorder  passes,  perhaps  suddenly,  into 
unmistakable  mania,  and  seclusion  becomes  necessary. 

A  remarkable  fact  amongst  the  phenomena  of  menstruation  is  the 
effect  on  'pigmentation.  The  complexion  is  commonly  changed ;  it  loses 
its  clearness,  becomes  dull  or  sallow,  and  a  dark,  even  black  ring, 
especially  marked  in  brunettes,  is  traced  around  the  eyes.  This  is  often 
so  conspicuous  as  to  reveal  to  the  initiated  what  is  going  on.  It  is 
similar  to  the  state  of  pigmentation  wrought  by  pregnancy,  and  thus 
aifords  evidence  of  the  analogy  or  relation  between  the  two  states.  Dr. 
Laycock  says  excessive  pigmentation  is  brought  about  by  imperfect 
oxidation  of  the  carbon ;  that  by  imperfect  elimination  of  the  carbon, 
in  deficient  menstruation,  diseases  of  the  liver  and  kidneys  are  induced  ; 
and  that  these  conditions  are  promoted  by  the  excessive  production  of 
carbon  from  the  use  of  highly  carbonized  food. 


PRIMITIVE    AMENORRHCEA.  16' 


CHAPTER    Xyill. 

DISOKDEKED  MENSTEUATION  (PARAMENIA,  W.  FAER)— 
AMENOPvEHCEA. 

The  departures  from  the  ordinary  character  of  healthy  menstruation 
are  conveniently  classified  under  amenorrhoea,  including  deiiciency  of 
the  flow;  Menorrhagia  indicating  excess,  and  dysmenorrhoea,  indicating 
that  the  function  is  performed  with  difficulty  and  pain.  These  terms, 
like  so  many  others  we  are  obliged  to  use  in  medicine,  do  not  represent 
any  definite  disease,  but  are  simply  general  descriptions  of  sym])toms. 
Under  each  of  them  the  most  widely  differing  pathological  conditions, 
mechanical  and  systematic,  are  grouped.  Many  different  pathological 
conditions  may  alike  lead  to  one  symptom  that  shall  be  more  promi- 
nent than  the  rest.  That  symptom  is  the  first  thing  that  fixes  atten- 
tion, and  for  which  the  patient  seeks  advice.  It  is  the  business  of  the 
physician  to  analyze  the  patient's  condition,  and  to  discover,  if  he  can, 
what  are  the  associated  phenomena,  and  what  is  the  cause  of  the  lead- 
ing symptom.  This  is  the  method  we  are  daily  forced  to  adopt  at  the 
bedside.  It  is  not  so  illogical  as  it  appears ;  it  is  eminently  practical ; 
it  exercises  the  diagnostic  faculty  in  the  most  invigorating  manner, 
and,  if  rightly  pursued,  leads  to  the  soundest  knowledge,  at  once  the 
most  satisfying  to  the  physician,  and  the  most  profitable  to  the  patient. 
We  will,  then,  take  the  symptom,  amenorrhcea,  search  out  the  condi- 
tions upon  which  it  depends,  and  study  the  various  forms  it  presents. 

Some  authors  associate  with  primitive  absence  of  menstruation  those 
cases  in  which  the  menses  are  retained  by  closure  of  the  genital  canal. 
Logically  and  pathologically,  it  is  obviously  more  rational  to  consider 
these  cases  apart.  They  will  be  discussed  under  "Retention"  and 
"  Atresia."  The  amenorrhoea  here  is  not  real.  There  is  secretion,  but 
excretion  is  mechanically  hindered ;  menstruation  is  occult.  The  most 
rational  division  of  amenorrhoea  is  into — 1.  Primitive,  that  is,  the  flow 
has  never  taken  place;  2.  Accidental,  or  secondary,  that  is,  the  func- 
tion has  at  some  time  been  established,  but  has  subsequently  been 
suppressed. 

Primitive  Amenorrhoea. — The  appearance  of  menstruation  may  be 
retarded  for  one  or  two  years  beyond  the  usual  age  without  any  obvious 
derangement  of  health.  But  in  a  large  number  of  cases,  concurrently 
with  non-menstruation,  a  remarkable  condition  of  the  general  system 
is  observed,  to  which  the  name  chloro-anosmia  or  chlorosis,  vulgo,  green- 
sickness, is  given.  A  marked  feature  of  this  condition  is  a  great  dimi- 
nution of  the  red  corpuscles  of  the  blood,  and  a  consequent  exccessive 
proportion  of  water.  A  thin,  pale  blood,  incapable  of  carrying  on  effi- 
ciently the  functions  of  nutrition,  respiration,  or  circulation,  flows  lan- 
guidly in  the  vessels.     Every  organ,  every  tissue  feels  the  want  of 


164  AMEXORRHCEA. 

adequate  nourishment  and  stimulus.  The  skin  and  mucous  membranes 
present  a  peculiar  pallor  tinged  with  green.  The  patient  is  unwilling 
to  make  any  exertion,  and  even  the  most  moderate  effort  is  followed  by- 
mental  and  physical  prostration,  or  an  outburst  of  hysteria.  The  taste 
and  appetite  are  often  depraved.  The  ordinary  diet,  as  meat  or  fish,  is 
rejected  with  loathing.  The  craving  is  usually  for  fruit,  cucumbers, 
jjickles,  vinegar,  or  things  in  which  sourness  predominates.  It  is  more 
than  probable  that  the  craving  for  these  things  is  the  cry  of  Nature  for 
a  supply  of  elements  which  the  degraded  blood  is  in  need  of;  it  should 
not,  therefore,  be  too  absolutely  thwarted.  In  some  cases  earthy  and 
alkaline  substances  chiefly  excite  the  morbid  appetite.  The  heart,  ill- 
nourished,  acts  feebly ;  it  endeavors  by  increased  frequency  of  beat  to 
make  up  for  the  deficiency  in  quality  of  the  blood  it  sends  into  the 
general  system.  It  is  easily  excited  to  hurried  action,  which  assumes 
the  well-known  character  of  palpitation,  and  which  may  on  pushing 
exertion,  such  as  ascending  stairs  or  hills,  too  far,  readily  lead  to  faint- 
ing. Excessive  irritability  of  the  heart  under  emotion  or  physical  ex- 
ertion is  the  characteristic  condition.  Severe  pain,  more  or  less  fixed 
under  the  heart,  is  commonly  complained  of.  Headache  is  very  com- 
mon, and  is  easily  induced  by  exertion  or  emotion. 

The  watery  state  of  the  blood,  the  general  laxity  of  all  the  tissues, 
including  the  walls  of  the  capillaries,  and  the  feeble  power  of  the  heart, 
lead  to  local  stagnations  and  to  effusions  of  serum  into  the  cellular 
tissue  of  depending  parts.  The  feet  especially  swell,  are  cold,  readily 
affected  by  chilblains.  The  hands  also  swell ;  and  this  would  be  fre- 
quently observed,  were  it  not  that  they  are  subject  to  constant  changes 
from  the  hanging  position.  The  face  gets  puffy,  bloated,  especially  so 
the  loose  tissue  of  the  eyelids.  The  muscular  system  is  flabby  and 
feeble,  incapable  of  bearing  any  strain  ;  and  pains  in  the  muscles  are 
easily  induced  by  even  moderate  exertion. 

Depending  upon  a  similar  systemic  condition  we  occasionally  see 
those  nodules  of  limited  hypersemia,  ecchyraosis,  and  hyperplasia,  which 
are  known  as  erythema  nodosum.  These  chiefly  appear  in  the  legs,  but 
sometimes  also  in  the  arms.  They  indicate  the  extreme  debility  of  the 
walls  of  the  vessels,  and  of  the  surrounding  tissues,  which  in  their 
healthy  state  contribute  so  much  to  the  support  of  the  vessels. 

The  normal  flow  of  blood  is  not  uncommonly  replaced  by  a  periodi- 
cal watery  discharge.  This  must  be  regarded  as  menstruation.  The 
vascular  system  yields  under  the  ovarian  stimulus  the  best  substitute 
for  healthy  blood  which  it  can  afford.  This  may  be  called  '^imperfect 
menstruation."  In  these  and  other  cases  it  is  not  uncommon  to  note  a 
persistent  leucorrhoea.  This  form  of  leucorrhoea  is  one  of  those  which 
are  not  the  result  of  some  physical  lesion  justifying  local  examination. 
The  discharge  seems  due  to  relaxation  or  want  of  tone  in  the  vessels 
and  mucous  membrane.  It  commonly  ceases  when  healthy  menstrua- 
tion is  restored. 

In  every  case  in  which  the  deficiency  of  red  globules  is  marked,  a 
blowing  sound,  recognized  as  the  ansemic  hruit,  is  heard  at  the  base  of 
the  heart,  and  extending  along  the  arterial  trunks  of  the  neck.  Where 
this  deficiency  is  extreme  there  is  commonly  heard  in  the  jugular  veins 


CHLOEO-AN^MIA.  165 

that  peculiar  and  characteristic  noise  known  as  the  hruit-de-diable,  or 
the  German  "  Nonnengerausch." 

This  sound  gives  not  only  precise  diagnostic  indication  of  the  maladv, 
but  its  intensity  affords  accurate  estimate  of  its  progress.  In  propor- 
tion as  the  quality  of  the  blood  improves  under  treatment  the  noise 
diminishes.  It  appears  to  be  directly  associated  with  the  relative  ab- 
sence of  the  red  globules.  When  these  are  present  in  due  proportion 
the  sound  is  no  longer  heard.  I  have  observed  this  sound  in  a  marked 
degree  in  anaemia  associated  with  menorrhagia ;  and  notably  in  some 
cases  where  there  was  suspicion  of  commencing  tuberculosis. 

In  some  of  these  cases  of  associated  chloro-ansemia  and  amenorrhoea 
it  is  not  easy  to  determine  which  is  the  primary  factor.  Is  the  want 
of  menstruation  the  cause  of  the  degraded  condition  of  the  blood?  Or, 
on  the  other  hand,  is  the  degraded  condition  of  the  blood  the  cause  of 
the  amenorrhoea?  If  we  could  tell  which  condition  came  into  existence 
first,  and  which  followed,  the  sequence,  if  constant,  would  settle  the 
question.  But  the  ovary  is  beyond  direct  observation;  we  are  almost 
limited  in  our  conclusions  as  to  its  activity  by  noting  the  subordinate 
phenomena  of  menstruation. 

One  fact  comes  out  prominently:  the  state  of  chloro-anasmia  stands 
in  constant  relation  to  the  menstrual  function.  It  seems  probable  that 
at  the  age  of  puberty,  ovulation,  which  ushers  in  such  a  striking 
revolution  in  the  economy,  stimulating,  almost  visibly,  development  of 
the  whole  system,  and  remarkably  of  certain  organs,  takes  at  least  an 
indirect  part  in  the  function  of  blood-making.  Or  to  put  it  in  an- 
other way :  that  evolution  of  the  system  at  puberty,  that  almost  sudden 
bursting  into  womanhood,  cannot  be  perfectly  accomplished  unless  the 
ovaries  give  the  impetus.  This  is  illustrated  by  the  occurrence  of  re- 
lapses. For  example,  a  girl  who  has  quite  recovered  from  one  attack 
of  chloro-ansemia,  may  again  fall  into  exactly  the  same  condition, 
amenorrhoea  attending. 

Chlorosis,  says  Virchow,  is  distinguished  from  leukaemia  in  this : 
the  entire  number  of  the  corpuscles  is  smaller.  In  leukaemia,  color- 
less corpuscles  in  some  sort  take  the  place  of  the  red  ones,  and  a  real 
diminution  in  the  number  of  the  cellular  elements  in  the  blood  is  not 
produced.  In  chlorosis  the  elements  of  both  kinds  become  less  numer- 
ous, without  the  occurrence  of  any  disturbance  in  the  numerical  rela- 
tion between  the  colored  and  colorless  corpuscles.  Anatomical  obser- 
vations, he  goes  on  to  say,  indicate  that  the  foundations  of  the  chlo- 
rotic  ailment  are  very  early  laid ;  for  the  aorta  and  the  larger  arteries 
are  usually,  and  the  heart  and  sexual  organs  frequently,  found  imper- 
fectly developed. 

To  originate  a  new  function,  to  bring  to  perfection  a  hitherto  unex- 
ercised power,  makes  larger  demands  on  the  strength  than  are  required 
for  its  continued  activity.  The  feeble  phthisical  child  fails,  as  the 
time  of  womanhood  approaches,  to  menstruate,  and  the  signs  of  chlo- 
rosis gradually  manifest  themselves. 

Numerous  instances,  however,  are  observed  in  which  after  menstrua- 
tion has  been  fairly  established  for  months  or  even  years,  chloro-anaemia 
almost  suddenly  makes  its  appearance,  and  entails  suppression  of  men- 


166  AME]!fOEEHCEA. 

struation,  partial  or  complete.  In  many  of  these  cases  emotion  plays 
an  important  part.  Jealousy,  disappointment  in  love,  the  "  sjiretse  in- 
juria formse"  are  often  the  immediate  antecedents.  No  one  who  has 
had  a  large  experience  can  fail  to  remember  numerous  examples  of  the 
powerful  influence  of  emotion  in  altering  the  quality  of  the  blood. 

At  the  advent  of  puberty,  organs  hitherto  existing  only  in  a  latent  or 
potential  condition,  almost  suddenly  come  into  the  foreground,  and  a  new 
function  that  dominates  the  whole  system  appears,  or  ought  to  appear. 
The  perfection  of  the  ovaries  undoubtedly  entails  the  evolution  of  the 
breasts  and  uterus,  and  provokes  a  rapid  development  of  the  wdiole 
frame.  To  a  certain  extent  this  general  physical  development  will 
take  place,  whether  ovulation  be  perfectly  performed  or  not.  But, 
then,  to  carry  out  the  full  change  in  the  ovaries,  certainly  a  fair  supply 
of  healthy  blood  is  requisite.  If  the  sudden  excessive  demand  for 
healthy  blood  requisite  for  this  purpose,  and  for  the  attendant  general 
physical  growth,  be  not  adequately  met,  menstruation  will  be  hindered. 
And  the  continuing,  although  impeded,  general  growth,  exhausting 
the  blood  supply,  quickly  induces  the  marked  blood-degeneration  wliich 
is  so  characteristic.  Things  once  at  this  stage,  a  vicious  circle  of  mor- 
bid action  and  reaction  is  established.  The  effect  in  its  turn  becomes  a 
cause  of  further  disease. 

On  the  other  hand,  it  is  observed  that  M^hen  the  quality  of  the  blood 
has  been  improved  under  the  use  of  suitable  remedies  and  hygiene, 
menstruation  usually  returns  ;  and  that  when  a  degraded  condition  of 
blood  is  induced  by  defective  nutrition,  or  subjection  to  bad  sanitary 
conditions,  menstruation  is  suppressed. 

The  influence  of  the  ovaries  is  at  times  strikingly  manifested,  as 
when,  under  the  influence  of  marriage,  ovulation  being  stimulated,  the 
chloro-ansemia  often  disappears. 

We  may,  perhaps,  best  sum  up  the  argument  by  stating  these  propo- 
sitions :  1.  That  the  due  action  of  the  ovaries  gives  an  important  stim- 
ulus to  innervation,  sanguification,  and  the  general  well-being.  2.  That 
the  due  action  of  the  ovaries,  as  of  other  organs,  depends  upon  their 
being  duly  nourished  by  a  supply  of  healthy  blood.  We  cannot  always 
tell  which  factor  is  first  in  default;  but  whichever  it  be,  a  vicious  circle 
of  action  and  reaction  becomes  established  as  soon  as  the  one  condition 
has  induced  the  other. 

It  has  been  happily  said  that  amenorrhoea  is  a  cry  of  distress  indi- 
cating something  wrong  in  the  organism. 

The  opposite  condition  of  plethora  will  sometimes  delay  menstrua- 
tion. Girls  suddenly  exchanging  a  poor  vegetable  diet  for  one  rich  in 
nitrogen,  whilst  neglecting  exercise,  are  apt  to  fall  into  this  state. 

A  very  frequent  complaint  attending  amenorrhoea  is  acute  pain  un- 
der the  left  breast,  in  the  intercostal  spaces,  in  the  sacral  region,  or  in 
the  temples.  These  pains  have  often  been  described  as  "  hysterical ;"  and 
the  hysterical  knee  of  Sir  Benjamin  Brodie  might  perhaps  be  classed 
under  the  same  head.  It  is  rather  a  form  of  neuralgia,  induced  by  the 
waste  of  nervous  force  in  wrong  directions. 

Arsenic,  iodide  and  bromide  of  potassium,  are  the  most  useful  reme- 
dies.    A  sponge  soaked  in  hot  water  held  to  the  temples  or  other  seat 


TREATMENT    OF    AM  ENORIIHCE  A.  167 

of  pain  brings  sensible  relief,  Simpson  speaks  highly  of  nickel,  as 
sulphate  or  phosphate,  in  half-grain  or  one-grain  doses. 

There  are  local  causes  of  primitive  ameriorrhoea.  The  most  free  from 
doubt  are  absence,  defective  development,  or  disease  of  the  ovaries  and 
uterus.  Some  of  these  conditions  will  be  discussed  under  "Atresia." 
It  is  not  easy  to  discover  defective  development  of  the  ovaries  ;  it  can 
at  best  be  inferred  from  the  existence  of  defective  development  of  the 
uterus,  and  the  defect  of  the  menstrual  functions.  But  this  is  far  from 
being  constant.  A  small  infantine  uterus  may  be  recognized  by  the 
touch,  and  measured  by  the  sound.  The  uterus  is  sometimes  only  an 
inch  and  a  half  or  two  inches  long,  the  cervix  or  vaginal-portion  is 
very  small,  the  os  uteri  a  small  round  aperture,  and  the  body  may  be 
deflected  to  one  or  other  side.  In  these  cases  there  is  commonly  sexual 
indiflerence.  Simpson's  galvanic  pessary  is  here  of  use.  It  stimulates 
the  growth  of  the  uterus,  and  I  have  several  times  seen  healthy  men- 
struation established. 

Cystic  and  malignant  diseases  of  the  ovarieg  are  rare  at  the  age  of 
puberty.  And  in  a  considerable  proportion  of  those  cases  which  occur 
at  a  later  period,  a  portion  of  the  gland,  adequate  to  form  ova,  which 
run  through  the  normal  phases,  and  escape,  evoking  the  attendant 
phenomena  of  menstruation,  may  for  a  long  time  resist  the  invasion  of 
the  disease.  This  residuum  of  efficient  ovary  may  easily  be  overlooked; 
its  possible  existence  must  be  borne  in  mind  when  we  meet  with  cases 
in  which  menstruation  has  continued  concurrently  with  even  extensive 
ovarian  disease. 

But  it  must  not  be  concluded  that  absence  or  imperfect  develoj)ment 
of  the  uterus  is  a  certain  exponent  of  absence  or  imperfect  develop- 
ment of  the  ovaries.  For  proof  that  the  ovaries  may  be  well  developed 
and  perform  their  function,  although  the  uterus  may  be  wanting,  I 
refer  to  a  case  observed  at  St.  George's  Hospital,  and  cited  at  length  at 
page  156. 

When  the  chloro-ansemia  has  lasted  some  little  time,  a  slow  chronic 
feverish  state  sets  in. 

The  treatment  of  this  form  of  amenorrhoea  should  be  governed  partly, 
at  least,  by  the  knowledge  of  the  influence  of  ovulation.  But  here,  as 
in  almost  every  case  which  the  physician  is  called  upon  to  treat,  we 
must  treat  the  symptoms,  alleviate  the  consequences  of  the  disease,  as 
well  as  attack  the  cause.  The  two  indications  can  generally  be  followed 
out  at  the  same  time.  Our  first  effort,  then,  should  be  to  improve  the 
condition  of  the  blood,  since  we  can  hardly  expect  the  ovaries  to  assume 
their  function  energetically  until  they  are  properly  nourished. 

It  is  accepted  as  an  axiom  in  medicine,  that  the  blood  being  deficient 
in  red  globules,  iron  is  the  remedy  jDa?'  excellence.  This  is  true ;  but  it 
requires  more  judgment  in  administering  it  than  is  often  shown.  Long 
clinical  experience  has  taught  me  the  general  law,  that  in  all  states  of 
blood-degradation,  whether  resulting  from  mal-nutrition,  from  wasting 
diseases,  or  from  hemorrhages,  iron  is  ill  tolerated  at  the  beginning.  In 
all  extreme  anaemic  states  the  febrile  irritability  I  have  adverted  to  is 
liable  to  be  aggravated  by  iron,  if  rudely  and  precipitately  "  thrown 
in,"  as  the  phrase  is.     The  tongue  gets  parched  and  brown,  indicating 


168  AMENOERHCEA. 

a  like  state  throughout  the  alimentary  canal,  inducing  constipation,  and 
generally  impeding  nutrition ;  violent  headache  ensues  ;  the  pulse  rises 
in  frequency.  The  true  indication  is,  first,  to  allay  vascular  irritability, 
so  as  to  prepare  the  system  to  assimilate  iron.  This  is  best  done  by 
salines,  of  which  I  believe  the  best  is  the  fresh  prepared  acetate  of  am- 
monia, the  old  spiritus  Mindereri.  If  freshly  made  it  is  not  only  more 
grateful  from  containing  a  quantity  of  carbonic  acid,  but  it  is  more 
efficacious.  A  little  nitrate  of  potash  may  sometimes  be  usefully  added ; 
and  in  almost  every  case  the  combination  of  some  light  tonic,  as  hop, 
cinchona,  or  calumba,  will  be  of  service.  So  marked  is  the  benefit 
often  arising  from  this  exhibition  of  salines,  that  one  cannot  resist  the 
conclusion  that  the  blood  is  in  want  of  salines  as  well  as  of  iron,  and 
that  the  saline  material  is  the  first  want.  This  view  is  confirmed  by 
what  is  observed  in  transfusion.  In  extreme  anaemia,  revival  has  fol- 
lowed the  injection  of  saline  fluids  into  the  veins. 

When  vascular  irritability  is  subdued,  when  the  secreting  organs 
have  been  brought  to  a  cleaner  and  healthier  state  by  salines  and 
aperients,  iron  may  be  cautiously  tried.  Nothing  surpasses,  probably, 
Griffiths's  mixture.  This  also  should  be  freshly  made.  There  is  a 
special  virtue  in  nascent  combinations.  We  can  hardly  trace  the  new 
forms,  or  estimate  the  loss  sustained  in  stale  preparations.  But  it  is 
very  nauseous ;  and  modern  chemistry  has  supplied  us  with  other  ex- 
cellent preparations  of  iron.  Almost  every  one  has  his  favorite  pre- 
scription. The  citrate  of  iron  and  ammonia,  which  may  be  given  in 
an  effervescent  state  if  desired,  is  an  excellent  medicine ;  it  is  generally 
easily  borne.  I  have  long  given  with  great  advantage  the  solution  of 
acetate  of  iron.  This  seems  easily  assimilable,  and  is,  perhaps,  the 
most  agreeable  of  all  ferruginous  preparations.  It  is  not  desirable  to 
give  large  doses.  Iron  should  rather  be  regarded  as  an  element  of  food 
than  as  a  medicine.  The  blood  wants  it ;  but  it  must  be  taken  in  such 
a  way  that  the  system  have  time  to  deal  with  it  like  other  food-elements, 
to  assimilate  it  and  convert  it  into  blood.  Iron  must,  therefore,  be 
given  for  a  considerable  time ;  that  is,  until  the  return  of  color  to  the 
cheeks  and  mucous  membranes,  the  vanishing  of  the  hruit-de-diable 
and  the  ansemic  souffle,  and  the  establishment  of  menstruation  announce 
that  the  system  has  regained  the  independent  power  of  carrying  on  the 
function  of  blood-making. 

Coindet  and  Boinet  extol  the  virtue  of  iodine  in  amenorrhcea. 
Trousseau  also  advises  it,  saying,  however,  that  it  comes  in  most  usefully 
after  iron.  Ever  since  I  followed  the  clinique  and  lectures  of  this 
admirable  physician  I  have  prescribed  iodide  of  potassium  in  a  con- 
siderable proportion  of  cases.  But  my  observation,  whilst  confirming 
most  distinctly  Trousseau's  opinion  of  its  efficacy,  has  led  me  to  prefer 
giving  it  before  proceeding  to  the  administration  of  iron.  It  seems  to 
me  to  occupy  an  intermediate  place  between  ordinary  salines,  wliich 
should  be  given  first,  and  chalybeates.  Iodide  of  potassium  may  be 
given  in  ten-grain  doses,  with  or  without  ammonia  and  bark,  two  or 
three  times  a  day. 

An  old  popular  remedy  is  saffron.    Trousseau  extols  it.    I  have  tried 


TREATMENT  OF  AMENORRHGEA.  169 

it  extensively,  but  generally  in  combination  with  iodide  of  potassium, 
so  that  I  am  unable  to  speak  positively  of  its  independent  virtues. 

The  restorative  power  of  iron  is  often  much  increased  by  the  addi- 
tion of  small  doses  of  strychnine.  Under  this  agent  the  nervous  sys- 
tem especially  acquires  more  tone. 

The  digestive  organs  display  the  same  sluggishness  which  oppresses 
every  function.  Constipation  is  frequent,  and  the  peristaltic  action  of 
the  Ijowels  requires  stimulation.  Purgatives  are  generally  necessary, 
and  the  favorite  ones  are  aloes  or  rhubarb  combined  with  myrrh  or  other 
stimulating  adjuvant.  Hoifman  said  he  had  seen  better  results  from 
Rufus's  pill — the  "  pilula  de  tribus" — consisting  of  myrrh,  aloes,  and  saf- 
fron, given  in  repeated  small  doses,  than  from  any  other  medicine.  The 
concurrence  of  experience  as  to  the  efficacy  of  this  pill  should  rescue  it 
from  neglect. 

Concurrently  with  the  use  of  these  medicaments,  diet  and  exercise 
must  be  carefully  studied.  The  diet  should  be  generous.  Milk  is 
especially  useful ;  but  a  fair  proportion  of  roast  meat,  vegetables,  and 
fruit  should  be  taken.  Wine,  of  Avhich  claret,  Carlowitz,  and  Rhine 
wines  are  the  best  suited,  or  beer  should  be  prescribed. 

Exercise,  mental  and  physical,  must  be  graduated  to  the  strength  and 
power  of  endurance  of  the  patient.  In  the  profound  impairment  of 
nutrition  which  affects  every  organ,  the  nervous  centres  cannot  supply 
the  requisite  nerve-force,  nor  are  the  weak,  pale,  flabby  muscles  capable 
of  strong,  or  sustained  exertion.  Every  tissue  has  to  be  regenerated. 
This  is  a  work  of  time,  and  during  this  period  care  must  be  taken  to 
make  exercise  keep  pace  with,  but  not  exceed,  the  growing  strength. 

The  aim  being  to  create  or  to  restore  the  "  habit  '^  of  periodical  men- 
struation, special  care  is  indicated  to  favor  any  molimen  that  may  re- 
veal itself  by  pain,  sense  of  heat  or  weight  in  the  pelvic  organs,  or  by 
nervous  or  vascular  phenomena  elsewhere.  This  may  often  be  success- 
fully done  by  the  use  of  warm  hip-baths — the  addition  of  enough  mustard 
to  act  as  a  slight  rubefacient  is  sometimes  useful — warm  vaginal  douches 
of  plain  water,  or  even  with  the  addition  of  sufficient  free  ammonia  to 
communicate  a  soapy  feel  to  the  water.  One  or  two  leeches  applied  to 
the  anus  or  inside  the  thighs  have  often  started  the  natural  uterine  se- 
cretion. These  means  act  by  derivation ;  they  determine  the  afflux  of 
blood  to  the  pelvic  organs. 

As  further  means  of  following  up  this  indication  Schoenbein  and 
Scanzoni  recommend  aloetic  enemata.  Golding  Bird  and  Duchenne 
advised  electricity.  This  agent  has  been,  I  believe,  extensively  tried  ; 
but  I  am  not  aware  that  it  has  quite  fulfilled  the  expectations  that  might 
primd  facie  be  reasonably  expected  from  it. 

Direct  excitation  of  the  uterus  has  been  resorted  to.  Light  applica- 
tion of  nitrate  of  silver  to  the  cervix  uteri  has  undoubtedly  been  suc- 
cessful. The  catheterization  of  the  uterus  has  been  said  to  be  service- 
able. The  wearing  of  an  ivory  or  metal  stem  in  the  uterus  has  also 
been  advised.  The  most  effectual  local  remedy  is  probably  the  gal- 
vanic pessary  of  Simpson.  But  there  are  obvious  objections  to  having 
recourse  to  these  topical  proceedings  in  single  girls,  and  the  cases  are 
not  many  in  which  less  objectionable  means  are  not  effectual. 


170  A  M  E  N  O  E  E  H  GB  A. 

I  mention,  but  without  approving,  a  proposal  of  Sir  James  Simpson 
to  dry-cup  the  interior  of  the  uterus.  He  described  the  proceeding  as 
consisting  of  the  introduction  of  a  tube  like  a  male  catheter,  furnished 
with  numerous  holes  at  the  end,  into  the  uterine  cavity,  and  then  being- 
attached  to  an  exhausting  syringe.  The  suction  power  attracts  blood 
to  the  mucous  surface. 
'  Probably  these  direct  local  excitants  or  derivants  are  the  only  true 
"  emmenagogues."  According  to  the  old  idea,  an  emmenagogue  is  a 
medicine  possessing  the  property  of  causing  the  menses  to  flow,  that  is, 
of  inducing  a  discharge  of  blood  from  the  uterus.  It  is  not  clear  that 
any  known  medicine  possesses  this  property  in  a  direct  or  immediate 
manner.  But  if  we  adopt  the  modern  theory  that  menstruation  is  a 
function  consisting  essentially  and  primarily  in  the  ripening  and  dis- 
charge of  an  ovum  from  the  ovary,  and  secondarily  of  a  discharge  of 
blood  from  the  tubo-uterine  mucous  membrane,  we  shall  see  still  fur- 
ther reason  to  doubt  the  reality  of  emmenagogues.  It  is  difficult  to 
imagine  how  any  agent  we  know  of  can  in  any  direct  or  immediate  way 
determine  ovulation.  Amongst  the  agents  capable  of  exciting  con- 
traction of  the  uterus,  strychnine  deserves  a  prominent  place.  But 
whatever  influence  it  may  have  as  an  emmenagogue,  it  owes  to  its  prop- 
erty as  a  tonic ;  certainly  it  has  no  power  of  directly  causing  the  men- 
strual flow. 

Iron,  which  enjoys  the  greatest  popular  reputation  as  an  emmena- 
gogue, undoubtedly  acts  by  first  gradually  restoring  the  quality  of  the 
blood,  and  improving  general  nutrition.  If  it  occasionally  acts  promptly, 
it  may  be  supposed  that  large  doses  of  iron  may  produce  temporary 
congestion  in  the  pelvic  organs.  But  I  have  not  met  with  unequivocal 
evidence  that  it  does  so  act,  and  I  have  known  the  exjjcriment  to  be 
repeatedly  tried  and  fail. 

So  in  the  amenorrhoea  of  phthisis,  menstruation  may  sometimes 
return  when,  under  cod-liver  oil,  iron,  quinine,  and  suitable  hygienic 
means,  the  disease  is  arrested,  and  a  comparatively  healthy  hsematosis 
has  been  gained.     But  no  one  would  call  cod-liver  oil  an  emmenagogue. 

It  is  interesting  to  observe  that  those  agents  which  appear  to  exert  a 
special  influence  upon  the  uterus  are  precisely  those  which  have  the 
property  of  checking  hemorrhage  from  that  organ ;  indeed,  the  bleed- 
ing is  checked  through  that  very  property  of  causing  contraction  of  the 
muscular  wall.  Thus  ergot,  which  possesses  the  most  undoubted 
power  to  originate  uterine  contraction,  possesses  also  the  power  of 
checking  hemorrhage.  It  has  no  obvious  action  as  an  emmenagogue. 
The  same  observation  applies,  although  in  a  less  degree,  to  quinine  and 
digitalis.  I  am  informed  by  Mr.  Cockburn,  an  eminent  surgeon  prac- 
ticing in  India,  that  in  that  country,  quinine  is  specially  apt  to  cause 
abortion  in  women  of  delicate  fibre.  Dr.  Fordyce  Barker  has  given 
satisfactory  evidence  of  its  power  as  an  oxytocic. 

Indian  hemp  again  is  credited,  I  believe  justly,  with  oxytocic  prop- 
erties; but  its  action  in  checking  uterine  hemorrhage  is  even  more 
certain. 

To  this  rule  galvanism  may  appear  to  be  an  exception.  The  powers 
of  galvanism  as  an  oxytocic,  and  even  in  originating  uterine  contrac- 


SECONDARY    AMENOREHCEA.  171 

tion,  Dr.  Radford  and  I  proved  some  years  ago.  And  it  is  regarded 
by  some  as  the  only  direct  emmenagogue. 

Many  of  the  factors  which  account  for  primitive  amenorrhoea  will 
also  induce  secondary  or  accidental  amenorrhoea.  Thus,  defective  nutri- 
tion, unhealthy  occupations  in  crowded,  ill-ventilated  rooms,  blood- 
tainting  from  exposure  to  sewage-emanations,  want  of  exercise  in  the 
open  air,  which  implies  privation  of  the  wholesome  influences  of  the 
sun,  will  all  prevent  the  advent  of  menstruation.  It  is  a  matter  of 
observation  that  girls  verging  on  puberty,  sent  to  boarding-school  or 
into  business  in  large  town  establishments,  commonly  fail  to  men- 
struate, whilst  the  function  often  is  accomplished  on  their  return  to 
free  life  in  the  holidays,  or  on  return  to  the  country.  In  these  cases  the 
blame  cannot  always  be  assigned  to  insufficient  food,  for  girls  working 
in  trades  in  cities  often  get  a  more  substantial  diet  than  they  were  pre- 
viously used  to.  What  is  wanting  is  outdoor  exercise,  and  less  rigor- 
ous strain  upon  the  mind  and  body. 

Cretinism  exerts  a  remarkable  influence.  Luuier  ("Nouveau  Diet, 
de  Med.  et  de  Chir.  Pratiques,"  1869)  says  "that  puberty  is  almost 
always  held  back,  or  is  only  developed  at  the  age  of  nineteen  or  twenty 
in  girls,  and  later  even  in  men.  The  cretin  remains  until  puberty 
what  he  Avas  in  the  first  childhood,  and  very  often  there  is  nothing  to 
distinguish  the  boy  from  the  girl." 

Dr.  Langdon  Down  tells  me  "  that  he  is  able  to  say  with  much  cer- 
tainty that  idiocy  retards  by  quite  two  years  the  first  appearance  of  the 
menses.  In  a  large  number  of  cases  it  is  much  more  postponed,  and 
sometimes  never  appears.  Necroseopic  inspection  of  idiots  reveals,  as 
a  rule,  want  of  development  in  the  ovaries  as  to  size.  Associated  with 
the  non-appearance  I  have  observed  considerable  increase  of  adipose 
tissue." 

The  causes  of  arrest  of  menstruation  are  numerous.  We  exclude,  of 
course,  the  physiological  suspension  during  pregnancy  and  lactation. 
When  an  organ  happens  to  be  in  a  state  of  physiological  activity,  it  is 
specially  liable  to  suffer  when  the  system  is  exposed  to  any  physical  or 
mental  shock.  Physiological  activity  implies  hypersemia;  under  sudden 
excitation  hypersemia  readily  passes  the  physiological  boundary,  and 
the  function  which  was  in  progress  is  arrested.  Hence,  exposure  to 
cold  and  wet  during  the  menstrual  flow  will  frequently  check  it.  It  is 
said  that  some  women  wilfully  avail  themselves  of  this  deleterious  in- 
fluence, in  order  to  escape  from  the  temporary  abandonment  of  their 
pleasures  which  menstruation  compels.  They  encounter  a  very  serious 
danger.  It  is  not  to  be  expected  that  the  effect  will  stop  short  just  at 
the  point  desired.  Ovaritis  and  pelvic  peritonitis  are  very  likely  to 
attend  this  violent  suppression,  and  permanent,  even  fatal,  mischief 
has  resulted.  Dr.  Whitehead  relates  a  case  in  which  menstruation 
was  suppressed  by  cold  which  ended  in  fatal  peritonitis.  There  was 
no  eff'usion  of  blood.  In  another  case  the  same  physician  found  all  the 
large  sinuses  of  the  brain  distended  to  their  utmost  limit,  gorged  witli 
black,  firmly-coagulated  blood ;  no  extravasation.  Menstruation  had 
been  suddenly  suppressed  by  intense  mental  emotion.  On  the  other 
hand,  it  must  not  be  concluded  that  decided  organic  change  in   the 


172  AMENORRHCEA. 

ovaries  necessarily  attends  the  sudden  suppression  of  menstruation. 
Aran  made  minute  examinations  upon  this  jioint.  His  results  were 
mostly  negative.  The  absence  of  any  serious  organic  lesion  is  further 
proved,  in  many  cases,  by  the  return  of  the  menstrual  function  at  no 
distant  date.  The  arrest  of  the  flow  must  therefore  be  regarded,  in 
some  cases,  as  a  reflex  phenomenon,  the  peripheral  or  centric  irrita- 
tion which  caused  the  suppression  causing  a  diversion  of  nerve-force 
and  of  blood  in  other  directions.  It  is  analogous  to  the  suppression  of 
epistaxis  under  the  application  of  a  cold  body  to  the  skin.  I  have 
lately  seen  a  remarkably  well-developed  young  woman  who  never 
menstruated  regularly  after  receiving  a  blow  on  the  side. 

Abrupt  suppression  is,  however,  often  marked  by  signs  of  local  dis- 
tress. Pain,  a  sense  of  fulness  in  the  pelvis  and  groins  are  felt.  If 
examination  be  made  by  touch,  the  uterus  is  found  to  be  tender,  and 
even  some  tumefaction  of  the  ovaries  may  be  detected.  The  vaginal- 
portion  is  injected.  Constitutional  disturbance  also  reveals  the  local 
trouble.     The  pulse  rises. 

Uterine  and  ovarian  disease  not  seldom  entails  amenorrhoea.  In- 
flammation may  suspend  it,  but  advancing  degeneration  of  the  ovaries 
is  more  likely  to  lead  to  complete  suppression.  That  menstruation  so 
often  goes  on  notwithstanding  the  development  of  enormous  ovarian 
tumors,  is  explained  by  the  fact  that  commonly  one  ovary  is  healthy, 
or  that  where  both  are  affected,  yet  some  portion  of  one  or  both  retains 
so  much  of  its  normal  structure  that  the  process  of  ovulation  goes  on, 
whilst  the  "  habit "  is  so  strong  that  even  slight  ovarian  nisus  provokes 
the  customary  flow  from  the  mucous  tract. 

Emotion,  sudden,  or  that  attending  a  great  change  in  the  mode  of 
life,  will  often  suspend  menstruation.  Thus  it  is  not  uncommon  to  ob- 
serve in  young  women  absence  of  the  menses  for  two  or  three  months 
after  marriage,  naturally  giving  rise  to  the  idea  that  pregnancy  has 
begun.  This  is  often  nothing  more  than  an  emotional  suspension.  In 
like  manner,  under  the  still  greater  emotion  of  illicit  connection,  the 
same  thing  occurs.  Passion,  depressing  news,  domestic  calamities, 
have  often  caused  so  great  a  shock  that  the  menses  have  been  arrested 
even  permanently. 

Amenorrhoea  frequently  follows  acute  diseases,  especially  fevers. 
Thus  I  have  seen  girls  who  had  exhibited  all  the  characters  of  healthy 
development  cease  to  menstruate  for  months  after  recovery  from  scar- 
latina or  typhoid  fever.  I  have  known  examples  of  amenorrhoea 
dating  from  simply  nursing  a  scarlatinal  patient.  Exposure  to  the 
poison  was  sufficient,  without  the  development  of  the  fever.  In  some, 
the  functions  are  for  a  long  time  irregular,  imperfectly  performed,  and 
the  constitution  is  manifestly  impaired.  In  particular,  the  complexion 
seldom  regains  its  original  clearness,  growth  is  checked,  and  the  tem- 
per is  more  uncertain  and  irregular.     Ague  may  have  a  similar  effect. 

In  some  cases  of  arrested  menstruation  I  have  suspected  the  existence 
of  disease  of  the  supra-renal  capsules.  In  these  the  arrest  came  on  at 
ages  between  thirty  and  forty ;  the  complexion  underwent  the  most 
marked  dirty  sallow  change,  freckles  and  spots  becoming  almost  black  ; 


SECONDARY    AMENORRHCEA.  173 

there  was  great  mental  depression  occurring  in  fits,  and  great  emacia- 
tion. 

Associated  with  amenorrhoea,  probably  as  cause,  there  may  some- 
times be  found  a  general  torpor  or  deficient  innervation  of  the  sexual 
system.  This  probably  implies  defective  evolution  of  the  ovaries. 
There  is  an  original  or  acquired  insensibility.  There  is  no  sexual  feel- 
ing. This  has  sometimes  been  observed  to  follow  a  labor ;  but  in 
many  cases  it  is  original,  and  is  attended  by  sterility.  Attendant 
upon,  or  resulting  from,  this  ovarian  defect,  there  is  commonly  imper- 
fect development  of  the  uterus.  In  amenorrhoea  following  labor,  the 
suppressed  ovarian  function  is  accompanied  by  super-involution  of  the 
uterus. 

Diagnosis. — In  studying  this  question  we  must  bear  in  mind  all  the 
conditions  associated  with  amenorrhoea;  we  must  review  the  history  of 
the  patient,  and  of  her  present  illness.  To  trace  the  circumstances 
under  which  the  absence  of  menstruation  commenced,  we  must  inter- 
rogate all  the  functions,  in  order  to  detect  disease  in  organs  unconnected 
with  the  genital  system.  The  exploration  of  the  chest  is  especially 
important,  on  account  of  the  frequent  relation  between  amenorrhoea 
and  phthisis.  And  in  many  cases  it  is  necessary  to  examine  the  vagina 
and  uterus  to  ascertain  if  there  be  any  physical  defect  or  obstruction 
to  the  excretion.  This  applies  to  married  as  well  as  to  single  women. 
The  possibility  of  pregnancy  must  not  be  lost  sight  of.  In  women 
approaching  the  climacteric  we  must  also  consider  how  far  the  amenor- 
rhoea is  natural.  The  signs  of  "  Retention "  will  be  discussed  here- 
after. 

Prophylaxy. — Many  of  the  causes  of  amenorrhoea  are  avoidable. 
Nevertheless  great  carelessness,  even  recklessness,  is  shown  in  en- 
countering them.  It  ought  to  be  needless  to  insist  upon  the  obser- 
vance of  repose,  physiological  and  physical,  at  .the  menstrual  periods, 
the  avoidance  of  exposure  to  cold  or  mental  disturbance.  Adults  may 
be  expected  to  take  care  of  themselves ;  but  young  girls  verging  upon 
puberty  require  the  Avatchful  care  of  a  mother.  Serious  mischief  often 
arises  from  their  being  taken  by  surprise  at  the  first  appearance.  Not 
being  forewarned,  in  their  alarm  they  may  seek  to  check  the  bleeding 
by  bathing  in  cold  water,  and  they  are  apt  to  commit  other  imprudent 
acts  which  may  suppress  the  natural  floAV,  and  lay  the  foundation  for 
serious  protracted  or  permanent  disease.  Many  girls,  for  example, 
have  never  menstruated  again. 

They  should  be  warned  then  to  dress  warmly,  to  avoid  excitement, 
and  to  keep  quiet  when  the  period  is  approaching  and  during  the  flow. 

The  course,  duration,  and  consequences  of  amenorrhoea  vary.  Where 
there  is  no  organic  disease,  as  tuberculosis,  and  the  subject  is  submitted 
to  proper  hygienic  and  medical  treatment,  the  function  is  generally  re- 
stored in  a  few  months.  But  in  those  cases  where  amenorrhoea  is  com- 
plicated with,  or  dependent  upon,  disease  in  the  heart,  lungs,  liver, 
kidneys,  or  ovaries,  we  can  look  with  no  confidence  to  the  end  of  the 
symptomatic  or  consecutive  disorder.  On  the  other  hand,  where  the 
defective  action  of  the  ovary  appears  to  be  inherent,  or  primary,  its 
long  continuance  often  entails  such  impairment  of  nutrition  and  in- 


174  AMENOERHCEA, 

nervation  as  to  give  rise  to  distant  organic  disease.  Where  there  exists 
hereditary  morbid  diathesis,  especially  tubercular,  the  evil  which 
might  otherwise  have  remained  latent  is  very  likely  to  be  developed. 

The  influence  of  protracted  amenorrhoea  upon  the  nervous  system  is 
almost  always  prejudicial,  and  is  sometimes  deplorable.  The  leading 
characteristic  is  want  of  power  or  tone.  The  general  physical  condition 
is  lowered ;  the  patient  is  unequal  to  more  than  moderate  muscular 
exertion ;  the  fits  of  irritable  temper  alternate  with  torpor ;  headache 
is  frequent ;  it  is  difficult  or  impossible  to  sustain  any  mental  effort ; 
memory  is  feeble;  and  in  some  instances  mania  or  dementia  has 
ensued. 

Amenorrhoea,  especially  if  attended  by  marked  chloro-ansemia,  is 
very  liable  to  merge  into,  to  induce  pulmonary  consumption. 

The  hygienic  care  is  of  great  importance.  Careful  watch  must  be 
kept  for  the  invasion  of  phthisis.  Hence  it  is  often  useful  in  amenor- 
rhoea, whether  there  exist  any  special  cause  for  apprehending  the  inva- 
sion of  tubercular  mischief  or  not,  to  winter  in  a  mild,  pure  air,  as  in 
Torquay,  Ventnor,  or  the  South  of  France  or  Italy. 

The  treatment  of  acute  amenorrhoea  from  accidental  suppression 
must  be  governed  greatly  by  the  nature  of  the  cause  of  suppression. 
If  it  be  the  result  of  cold,  a  warm  bath,  rest  in  bed,  sudorifics,  as 
acetate  of  ammonia,  ipecacuanha,  a  moderate  opiate,  or  terebinthinate 
eneraata  will  be  useful. 

But  if  there  be  evidence  of  pelvic  congestion  or  inflammation,  it 
will  be  unwise  to  seek  to  provoke  the  menstrual  flow  by  local  exci- 
tants. If  there  be  much  pain,  increased  on  pressure,  a  quickened 
pulse  with  hot  skin,  some  leeches  applied  to  the  groins  or  anus,  hot 
fomentations  to  the  stomach,  salines,  constitute  the  best  treatment. 
When  the  pain  has  come  on  very  suddenly,  and  with  great  severity, 
there  is  reason  to  fear  that  an  effusion  of  blood  has  taken  place  from 
the  turgid  Fallopian  tubes  or  ovaries  into  the  peritoneum.  This  case 
will  be  discussed  under  "  Hsematocele." 

Chronic  amenorrhoea  usually  falls  practically  under  the  same  rules  as 
the  primitive  amenorrhoea.  Iodide  of  potassium,  iron,  strychnine, 
suitable  hygiene,  are  our  chief  resources. 


BETENTION    OF    CATAMENIA.  175 


CHAPTER  XIX. 

AMENORRHCEA  FROM  RETENTION— RETAINED  MENSES  FROM  OC- 
CLUSION OR  ATRESIA  OP  THE  UTERUS,  VAGINA,  OR  VULVA, 
OR  FROM  IMPERFORATE  HYMEN— OCCULT  MENSTRUATION— 
H^MATOMETRA. 

The  study  of  those  cases  in  which  amenorrhoea  is  only  apparent,  in 
which  the  secretion  is  effected,  but  is  retained  in  the  cavities  of  the 
uterus  or  vagina,  will,  for  clinical  reasons,  be  most  conveniently  under- 
taken here.  In  its  practical  bearings  it  will  be  found  naturally  to  take 
its  place  between  amenorrhoea  and  dysmenorrhoea. 

The  history  and  symptoms  of  retained  menses  very  much  resemble 
those  of  dysmenorrhoea.  In  some  cases  they  simulate  pregnancy.  In 
other  cases,  for  a  considerable  tira£,  the  negative  sign  of  absence  of 
the  ordinary  menstrual  flow  chiefly  attracts  attention;  and  they  are 
looked  upon  simply  as  cases  of  amenorrhoea. 

The  leading  clinical  feature  is  the  combination  of  signs  of  dys- 
menorrhoea with  amenorrhoea.  And  since  retention  commonly  induces 
enlargement  of  the  uterus,  and  hence  of  the  abdomen,  the  combina- 
tion of  amenorrhoea  and  this  enlargement  leads  to  the  suspicion  of 
pregnancy.  When  things  have  arrived  at  this  point,  the  character  of 
the  patient,  no  less  than  the  physical  distress  and  danger,  impera- 
tively point  to  the  necessity  of  an  examination. 

The  usual  history  is  as  follows:  A  girl  having  arrived  at  puberty, 
does  not  menstruate.  Month  after  month,  perhaps  for  two  or  three 
years  or  more,  pass  by,  and  nothing  is  seen.  But  every  month, 
perhaps  with  occasional  intermission  of  a  month,  pains  in  one  or 
other  iliac  fossa,  such  as  commonly  indicate  difficult  ovulation,  are  felt; 
pain  in  the  centre  of  the  pelvis  referred  to  the  uterus  follows  or  pre- 
cedes, often  of  a  forcing  or  bearing-down  character,  that  is,  uterine 
colic,  such  as  occurs  when  the  organ  is  struggling  to  expel  something 
from  its  cavity;  frequently  the  pain  spreads  to  the  abdomen,  so  that 
the  patient  cannot  bear  to  be  touched,  and  suggesting  the  presence  of 
peritonitis.  With  these  pains  there  is  often  flushed  face,  accelerated 
pulse,  headache,  vomiting,  pains  down  the  legs,  irritation  of  the  bowels 
and  of  the  bladder. 

After  a  few,  days  these  symptoms  subside,  seldom  entirely ;  and  the 
patient  is  left  to  an  interval  of  comparative  ease.  But  her  general 
health  suffers.  A  degree  of  irritability  of  nervous  system  remains. 
Not  seldom,  occasional  rigors  appear,  and  these  are  followed  by  quickened 
pulse,  increased  temperature,  nausea,  muddy  complexion ;  in  short,  the 
usual  signs  of  blood-infection.  When  irritative,  hectic,  septicaemic,  or 
pysemic  fever  sets  in,  the  case  is  commonly  hastening  to  a  climax ;  and 
the  physician  is  soon  compelled  to  search  for  the  source  of  the  disorder. 
The  periodical  pelvic  pains,  the  amenorrhoea,  and  the  frequent  compli- 
cation, with  evidence  of  peritonitis,  direct  him  to  the  uterus. 


176  ATRESIA    OF    THE    GENITAL,    CANAL. 

In  other  cases,  the  irritative  fever,  although  existing  in  a  minor 
degree,  is  not  the  immediate  cause  of  chief  distress.  This  is  due  to 
the  distension  of  tlie  uterus,  or  vagina,  or  both,  progressing  so  as  to  dis- 
tend the  abdomen.  The  pain,  causing  vomiting  and  prostration,  may 
be  so  great  that  the  local  source  cannot  be  overlooked.  The  enlarged 
uterus  may  press  the  bladder  forwards,  and  jam  it  against  the  symphysis 
pubis,  causing  retention  of  urine.  The  distress  arising  from  this,  and 
the  added  enlargement  of  the  abdomen,  admit  of  no  delay. 

In  other  cases  the  enlargement  of  the  abdomen  is  slow,  and  the  pain 
is  tolerated ;  and  it  is  only  when  amenorrhoea  and  enlargement  of  the 
abdomen  excite  suspicion  of  pregnancy  that  medical  advice  is  sought. 
In  some  of  these  cases  the  history  of  the  enlargement,  extending  over 
alonger  period  than  the  normal  time  of  gestation,  and  other  circum- 
stances, independently  of  the  moral  character  of  the  sufferer,  are  enough 
to  remove  all  doubt  of  her  chastity  from  the  minds  of  all  but  the 
censorious. 

The  governing  fact,  then,  is  retention  of  the  menstrual  fluid  in  the 
uterus  or  vagina.  There  is  secretion,  but  not  excretion.  Menstruation 
is  non-apparent,  but  it  exists.  The  proper  term,  then,  is  not  amenor- 
rhoea, or  amenorrhoea  from  retention,  which  is  a  contradiction  in  terms, 
but  ^'  occult,  or  concealed  menstruation." 

The  ovaries  act,  the  uterus  responds,  the  menstrual  blood  is  secreted, 
but  owing  to  some  physical  obstruction  it  cannot  be  excreted ;  that  is, 
it  is  retained.  These  cases  may  be  divided  into  two  kinds  :  1 .  There 
is  retention  ah  initio ;  there  is  some  congenital  defect,  or  some  condi- 
tion acquired  in  childhood;  2.  The  retention  has  arisen  after  puberty, 
and  most  frequently  after  childbearing,  and  is  the  consequence  of  an 
obstruction  acquired  after  maturity. 

We  have,  then,  to  examine  the  cases  of  Atresia  of  the  Vulva,  Vagina, 
and  Uterus,  and  the  other  defects  offorTMition  which  lead  to  retention  of 
menstrual  secretion. 

Atresia  (from  «  rpy^fftq,  a  hole)  of  the  genital  canal  may  be  congenital 
or  acquired,  primitive  or  secondary.  The  congenital  conditions  con- 
sist in  abnormal  formation  from  imperfect  or  defective  or  excessive 
development. 

Atresia  or  occlusion  may  be  coraj)lete  or  incomplete,  the  degrees  of 
incomplete  atresia,  of  course,  varying  greatly.  The  incomplete  occlu- 
sions, differing  somewhat  in  their  pathological  and  clinical  history,  will 
be  discussed  in  succeeding  chapters  under  otiier  heads,  as  "Dysmenor- 
rhoea,"  &c.  In  this  place  I  propose  to  describe  the  history  of  occlusion, 
complete,  or  so  nearly  complete,  that  the  cases  strictly  fall  under  the 
same  category. 

Atresia  may  affect  any  part  of  the  genital  tract  from  the  vulva  to 
the  uterus,  and  even  to  the  Fallopian  tubes.  It  will  be  convenient  to 
begin  with  the  description  of  occlusion  of  the  vulva,  and  to  ascend 
from  this  point. 

Puech  distinguishes  three  kinds  of  closure  of  the  T^ufoa;  1.  Adhesion 
•of  the  labia  majora,  always  of  accidental  origin,  the  result  of  inflam- 
mation or  injury ;  2.  Adhesion  of  the  labia  minora,  also  the  result  of 
accident,  and  like  the    first,  chiefly  distressing  from  impediment  to 


ATRESIA     OF    THE     GEXITAL     CANAL.  177 

micturition ;  3.  Hymenial  atresia,  the  most  common,  and  usually 
spoken  of  as  imperforate  hymen,  generally  congenital.  It  may  come 
under  notice  before  puberty  from  the  collection  of  mucus  in  the  vagina 
causing  distension,  or  it  may  be  detected  soon  after  birth.  I  have 
several  times  incised  an  imperforate  hymen  in  infants. 

The  closure  of  the  vagina  may  be  congenital  or  accidental.  The 
congenital  kinds  may  be  formed  by  transverse  membranous  septa,  com- 
posed of  the  folds  of  mucous  membrane  with  some  connective  tissue  or 
muscular  fibres  between.  In,  some  cases,  imperforation  of  the  cervix 
uteri  complicates  that  of  the  vagina.  The  accidental  closure  of  the 
vagina  is  far  more  frequent;  it  is  almost  always  the  consequence  of 
cicatricial  contraction  after  injury  or  inflammation.  The  walls  cohere ; 
the  vagina  is  more  or  less  perfectly  obliterated. 

True  occlusion  or  atresia  is  commonly  the  result  of  a  cicatricial  pro- 
cess following  upon  ulceration,  granulation,  or  laceration  of  the  os 
uteri.  The  most  frequent  cause  is  laceration  or  sloughing,  arising  from 
severe  labor,  with  or  without  instrumental  aid.  It  has  been  caused  by 
burns  suffered  during  childhood ;  by  cauterization  of  the  os  uteri  with 
potassa  fusa ;  from  cicatrization  following  inflammation  in  small-pox, 
scarlatina,  typhoid ;  from  sloughing  of  the  mucous  membrane  of  the 
.vagina,  from  use  of  a  too  concentrated  solution  of  perchloride  of  iron 
(Tessier,  Gaz.  des  Hop.,  1869);  after  amputation  of  the  cervix,  for 
want  of  sufficient  care  to  maintain  the  patency  of  the  canal  during 
cicatrization ;  also  from  advancing  senile  atrophy,  which  produces  a 
kind  of  concentric  obliteration  of  the  os.  Rokitansky  describes  this 
last  form.  I  have  seen  many  examples  of  it.  Ivlob  describes  a  peculiar 
form  of  obliteration  of  the  os  externum  as  following  upon  prolapsus, 
with  inversion  of  the  vagina ;  in  these  cases  a  small  pit  alone  shows  the 
seat  of  the  os,  and  the  atresia  is  caused  by  a  milk-white  membrane 
formed  of  several  layers  of  vaginal  epithelium. 

Closure  of  the  uterus  most  frequently  takes  place  at  the  os  internum 
or  OS  externum.  It  may  be  the  result  of  extrinsic  causes,  as  from  ex- 
ternal pressure  of  tumors ;  froiu  flexions  of  the  uterus,  more  especiallv 
from  bending  of  the  body  forwards  or  backwards  upon  the  neck,  so  as 
to  form  an  acute  angle  at  the  seat  of  flexion ;  from  tumefaction  of  the 
mucous  membrane,  as  from  catarrhal  or  other  inflammation ;  from  the 
growth  of  cancerous  or  fibroid  tumors  in  the  substance  of  the  neck ; 
from  plugging  by  clots,  membranous  substances,  or  pseudoplasmata. 
These  conditions  may  be  diagnosed  from  true  atresia,  and  sometimes 
may  be  relieved  by  passing  the  uterine  sound. 

Another  form  of  closure  is  due  to  the  sealing  of  the  os  externum  or 
internum  by  a  false  membrane,  as  described  by  Naegele.  This  has 
been  observed  to  take  place  during  pregnancy,  so  that  at  the  time  of 
labor  no  os  uteri  could  be  felt. 

Absence  of  uterus,  according  to  Kussmaul,  is  very  rarely  complete. 
Even  when  exploration  is  made  by  finger  in  rectum  and  sound  in 
bladder,  a  rudimentary  uterus  may  evade  detection  by  slipping  on  one 
side.  Even  on  dissection,  unless  very  carefully  conducted,  a  rudimen- 
tary uterus  may  escape  detection.     In  one  case  (Perkins,  cited  by  How- 

12 


178  RETENTION    IN    DOUBLE     UTERUS. 

ship)  the  uterus,  containing  two  pounds  of  blood,  was  found  behind 
the  closed  vagina. 

An  apparently  absent  vagina  is  no  proof  of  absent  uterus.  An 
artificial  route  has  several  times  been  made  to  the  distended  uterus. 
(Amussat.) 

In  some  of  these  cases  of  absent  vagina  the  os  uteri  has  opened  into 
the  rectum  or  urethra,  and  these  canals  being  used  by  the  intromittent 
organ,  impregnation  has  occurred.  According  to  Dr.  Oldham,  there 
is  in  many  cases  of  closure  or  malformation  of  the  vagina,  an  original 
dilatation  of  the  urethra,  a  circumstance  which  has  embarrassed  the 
examining  surgeon.  This  enlargement  of  the  urethra  has  been  com- 
monly supposed  to  be  the  result  of  accidental  or  voluntary  substitu- 
tion of  the  urethra  as  a  copulative  organ ;  but  Dr.  Oldham  is,  no 
doubt,  right  in  recognizing  it  as  pre-existing  and  independent  of  this 
use.  Dr.  Routh  related  a  case  {Obstetrical  Trans.,  1870)  confirmatory 
of  Dr.  Oldham's  view.  It  may,  however,  be  due  in  some  cases  to 
surgical  examinations.  Uterhart^  relates  a  case  of  nearly  complete 
occlnsion  of  the  introitus  vaginae  by  cicatricial  degeneration,  in  which 
the  function  of  the  vagina  was  performed  by  the  dilated  urethra.  The 
defect  was  cured  by  operation.  The  urethra  then  contracted  to  its 
normal  state. 

Spencer  Wells  [Med.  Times  and  Gaz.,  1870)  relates  cases  where  the 
meatus  was  used  for  the  vagina,  although  the  vagina  existed  closed  by 
hymen.  In  one  case  the  vagina  was  apparently  wanting,  but  menstru- 
ation was  regularly  performed  through  a  small  fistula  between  the 
urethra  and  anus.  This  being  incised,  an  opening  was  made  into  a 
well-formed  vagina  above,  the  normal  os  uteri  opening  into  it. 

It  is  remarkable  that  retention  has  frequently  been  observed  where 
the  uterus  was  tw^o-horned,  or  double.  One  uterus  is  occluded,  and 
becomes  the  seat  of  retained  menstrual  fluid,  whilst  the  other  uterus 
performs  its  function  normally,  or  is  the  source  of  metrorrhagia. 
Dec&s  {Bull,  de  la  Sog.  Anat,  1854)  tells  a  case  in  which  retention  in 
one  uterus  led  to  rupture  of  the  horn,  and  fatal  peritonitis.  Leroy 
{Journ.  des  Connaiss.  Med.,  1835)  published  a  case  in  which  there  was 
occlusion  of  the  right  uterine  neck,  retention  of  menstrual  flux,  and 
formation  of  a  tumor  reaching  to  the  umbilicus  and  simulating  preg- 
nancy. Rokitansky  relates  an  important  case  {Zeitsch.  d.  Gesellsch.  d. 
Aerzte,  1860).  He  dissected  a  woman  who  died  under  symptoms  of 
pelvic  inflammation.  The  uterus  had  a  complete  septum.  The  right 
half  only  communicated  with  the  vagina,  which  was  single.  The  left 
half  was  shut  oif  from  the  vagina,  and  expanded  into  a  pouch  con- 
taining a  dirty  ichorous  matter.  This  pouch  formed  a  fluctuating  pro- 
jection into  the  roof  of  the  vagina.  The  septum  between  the  two 
uteri  was  perforated  by  ulceration.  Rokitansky  concluded  that  there 
had  been  imprisonment  of  menstrual  fluid  in  the  blind  half  of  the 
uterus,  causing,  first,  distension  of  the  cervix,  then  inflammation  and 
perforation  of  the  septum,  with  consensual  inflammation  of  the  collat- 
eral (left)  ovary,  leading  to  abscess  and  peritoneal  effiision.     Dr.  Be- 

1   Berlin,  Klin.  Wochcnschrift,  1809. 


ATEESIA     OF    THE     GENITAE    CANAL. 


179 


rouius  relates  a  similar  case  {Mon.f.  Gehur^tsk.,  1862).  The  distended 
half  of  the  uterus  was  punctured ;  but  death  ensued  from  acute  peri- 
tonitis in  thirty-six  hours. 

Dr.  Breisky  relates  the  following  case.*  A  girl,  when  sixteen  years 
old,  began  to  suifer  from  uterine  colics  every  four  weeks,  no  discharge 
appearing.  The  pain  was  most  severe  in  the  right  side,  and  the  abdo- 
men became  gradually  larger  after  every  period.  Constipation  and 
extreme  anssmia  followed ;  then  difficult  micturition.  Suddenly  she 
felt  something  burst,  and  a  quantity  of  pale-red,  thick,  stinking  fluid 
escaped,  to  her  great  relief.  Discharge  returned  irregularly  during  a 
year,  at  times  like  thin  pus.  Breisky  punctured  by  the  side  of  the  os 
uteri,  and  let  out  a  quantity  of  pus.  He  concluded  that  the  seat  of  the 
abscess  was  the  right  uterus. 

G.  Simon  relates'^  a  case  of  congenital  atresia  of  the  left  half  of  the 
vagina  at  the  vulva,  with  duplex  uterus.     There  w^as  retention  of  men- 


FiG.  51. 


From  a  preparation  in  St.  George's  Museum.    (Half  size.) 

r,  dilated  uterus;  v,  dilated  vagina  above  the  seat  of  atresia,  traversed  by  B,  a  piece  of  bougie.  The 

Fallopian  tubes  are  not  dilated. 

struation  in  the  closed  half,  and  contemporaneous  metrorrhagia  from 
the  open  half. 

In  the  senile  form  of  occlusion,  pain  of  an  acute  kind  ensues  when- 
ever there  is  any  secretion  forming  in   the  cavity  of  the  uterus.     In 


1  Archiv  fiir  Gyniikologie,  1871. 


2  Monatsschrift  fiir  Gebiirtskunde,  1864. 


180 


ATRESIA    OF    THE    GENITAL    CANAL. 


women  in  whom  the  menstrual  function  has  ceased,  there  sometimes 
exists  a  form  of  catarrhal  inflammation  of  the  lining  membrane  of  the 
uterus,  giving  rise  to  a  mucous  or  muco-purulent  secretion,  which, 
being  retained,  produces  symptoms  resembling  those  from  retained 
menstrual  blood.  If  the  fluid  is  watery,  this  is  called  hydrometra. 
The  uterus  seldom  attains  a  size  comparable  to  that  observed  in  cases 
of  retained  menses  ;  but  the  cavity  is  always  somewhat  enlarged.     On 


Fig.  52. 


From  specimen  in  EadclifFe  Museuna,  Oxford— (case  described  by  Dr.  Tuckwell.)   (One-third  size.) 

u,  cavity  of  vagina  distended ;  o  m,  os  uteri,  and  cavity  of  uterus  above  it  also  distended. 

Complete  occlusion  of  vulva. 


examining  by  the  finger,  the  uterus  is  felt  enlarged,  often  retroflected: 
the  OS  externum  is  sometimes  difficult  to  make  out,  from  the  vaginal- 
portion  of  the  uterus  being  atrophied,  and  so  leaving  the  os  flush  with 
the  roof  of  the  vagina.  Generally,  however,  the  point  of  the  sound 
will  penetrate  a  little  way;  and  by  persevering  with  gentle  pressure, 
sometimes  a  passage  is  gradually  found  into  the  uterus. 

There  is  a  feature  in  the  history  of  stenosis  and  atresia  of  the  genital 
canal,  which  it  is  interestina:  to  describe,  on  account  of  its  bearino-  on 


RETENTION    OF    MENSTRUAL     FLUID.  181 

treatment.  Under  the  condition  of  stenosis  or  atresia  long  persisting, 
this  canal  obeys  the  same  law  which  rules  over  other  canals  or  hollow 
organs.  It  undergoes  retrograde  dilatation  above  the  seat  of  stricture. 
This  is  the  almost  inevitable  consequence  of  the  futile  attempts  of  the 
muscular  coat  to  expel  the  retained  contents.  This  successive  ascending- 
dilatation  of  vagina,  cervix,  body  of  uterus  and  tubes,  is  illustrated  in 
Figs.  51  and  52,  taken  from  preparations  in  St.  George's  and  the  Rad- 
cliffe  Museums.  This  effect  is  seen  in  the  most  marked  form  in  cases 
of  imperforate  hymen.  The  vagina  being  the  most  distensible  part  of 
the  canal  dilates  first,  forming  a  large  pouch ;  then  the  cervix  uteri  is 
distended ;  then  the  cavity  of  the  body  of  the  uterus ;  and  lastly,  the 
Fallopian  tubes.  This  dilatation,  conservative  in  its  effect  by  accom- 
modating the  contents  which  cannot  be  evacuated,  has  its  limits.  When 
these  are  reached,  the  danger  of  rupture  or  perforation  at  the  weakest 
part  is  great.  But  before  this  comes  to  pass,  there  are  two  events  which 
may  happen.  The  first  is  transudation  of  the  more  fluid  part  of  the 
contents  under  the  concentric  compression  to  which  it  is  subjected. 
The  experiments  of  Dr.  Matthews  Duncan,  to  which  I  have  before 
referred,  show  that  under  a  certain  degree  of  hydraulic  pressure,  air  or 
liquids  penetrate  the  entire  wall  of  the  uterus.  This  is  the  old  experi- 
ment of  the  Florentine  metal  globe  applied  to  organic  tissues.  His 
experiments,  of  course,  were  performed  on  dead  tissue.  But  it  appears 
to  me  that  there  is  good  reason  to  believe  that  the  force  which  the 
living  uterus  exerts  in  its  efforts  to  expel  what  may  be  in  it,  whether 
it  be  a  foetus  or  imprisoned  fluids,  is  enough  to  drive  fluid  through  its 
walls,  in  the  form  of  a  fine  oozing  or  dew,  which  hangs  on  the  peri- 
toneum. It  seems  to  me  probable  that  it  is  in  this  way  that  some  cases 
of  puerperal  pelvic  peritonitis  are  produced ;  and  I  have  seen  cases  of 
septicaemia  and  peritonitis  occurring  from  retention  of  menstrual  fluid, 
greatly  resembling  puerperal  fever,  in  which  there  was  no  rupture,  and 
no  escape  of  fluid  by  the  open  ends  of  the  Fallopian  tubes. 

Supposing  that  the  structures  retain  their  integrity,  it  is  natural  that 
the  concentric  compressive  force  should  drive  the  contents  along  any 
passage  that  may  be  pervious;  hence  the  escape  by  preference  along 
the  tubes.  This  is  rendered  more  likely  by  the  dilatation  which  com- 
monly takes  place  at  their  uterine  ends. 

This  compressive  force  is  exerted  with  most  effect  immediately  after 
the  puncture  of  the  closed  hymen.  The  sudden  collapse  of  the  walls 
of  the  uterus  ensuing  upon  the  partial  escape  by  the  opening  excites 
the  uterus  to  contract.  This  contraction  drives  the  contents  in  all  the 
three  directions,  and  some  will  probably  escape  through  one  or  other 
of  the  tubes  into  the  peritoneal  cavity. 

The  more  common  event  is  the  laceration  of  the  tubes  at  the  weakest 
place,  caused  by  the  sudden  dragging  upon  them  by  the  retreating 
uterus,  the  tubes  being,  perhaps,  held  back  by  adhesions. 

Other  consequences  of  retention,  if  not  relieved  by  operation,  are : 
the  distension  of  the  uterus  leads  to  perimetritis,  with  adhesion  to  the 
surrounding  parts,  especially  of  the  Fallopian  tubes  to  the  ovaries  and 
broad  ligaments.  The  thinning  of  the  uterus  may  proceed  to  burst- 
ing.    The  distended  Fallopian  tubes  may  burst,  or  without  bursting,. 


182  EETAINED     MENSTRUAL     FLUID. 

an  overflow  of  blood  may  escape  into  the  peritoneum,  causing  peri- 
tonitis. (Brodie,  Kiwisch.)  Beclard  relates  a  case  in  which  the  uterus 
burst,  discharging  into  the  bladder.  Scanzoni  and  Dr.  Arthur  Farre 
relate  cases  in  which  the  distended  hymen  burst;  in  Dr.  Farre's  case 
death  resulted.  In  other  cases  the  obstructing  membrane  has  given 
way  under  a  process  of  ulceration,  and  a  cure  has  resulted.  (See  cases 
in  Puech.) 

The  constitution  suffers  from  hectic,  the  result  of  pain,  and  the 
absorption  of  the  altered  blood  from  the  uterus.  In  some  cases — 
Liz6  relates  one  [Union  3Iedicale,  1863) — the  impossibility  of  evacuat- 
ing the  collecting  menstrual  blood  induces  amenorrhoea;  the  ovaries 
and  uterus  give  up  their  functions.  Lize  believed  that  in  his  case 
atrophy  of  the  uterus  was  induced.  Dr.  Murray,  of  Newcastle,  relates 
a  case  {Brit.  3fed.  Journ.,  1868),  of  a  single  lady,  aged  twenty-seven, 
whose  vagina  was  closed  by  small-pox  in  infancy.  Menstruation  had 
been  suspended  for  fourteen  years.  The  vagina  being  opened  up,  no 
collection  was  found  in  the  uterus,  but  exactly  a  month  afterwards 
menstruation  appeared,  and  recurred  with,  tolerable  regularity  after- 
wards. In  this  case  it  was  clear  that  the  ovaries  were  not  atrophied, 
but  that  the  uterus  ceased  to  pour  out  menstrual  blood.  This  is  in 
accordance  with  what  sometimes  occurs  in  apparent  amenorrhoea,  with- 
out uterine  obstruction.  Ovulation  may  go  on  without  exciting  men- 
strual flow.  This  returns  when  a  healthy  state  of  the  blood  is  restored. 
Simon  relates  [Mon.f.  Geburtskunde,  1851)  a  case  of  complete  closure 
of  the  vagina,  with  a  distended  uterus.  Vain  attempts  w^ere  made  to 
establish  a  vagina.  The  patient  maintained  good  health  without  the 
uterus  being  opened. 

I'he  character  of  the  retained  blood  is  remarkable.  It  is  dark-colored, 
deficient  in  fibrin,  of  treacly  consistence,  rarely  containing  coagula; 
it  contains  mucus,  and  often  cholesterin  scales.  It  is  glutinous,  in- 
odorous. The  quantity  varies  with  the  duration  of  retention.  Occa- 
sionally the  tolerance  and  accommodation  are  surprising;  the  uterus 
may  be  expanded  to  the  size  of  the  end  of  pregnancy.  Ten  pounds  of 
blood  have  been  collected;  I  have  collected  forty  ounces,  and  this  per- 
haps LS  an  average  amount.  Puech  deduces  from  comparison  of  quan- 
tity and  time  of  retention  that,  as  a  rule,  the  quantity  is  less  than  the 
number  of  menstrual  periods  would  have  produced  normally. 

Letheby  {Lancet,  1845)  analyzed  forty  ounces,  which  gave  water, 
875.4;  albumen,  69.4;  globulin,  49,1;  hematosin,  2.9;  salts,  8.0;  fiit, 
5.3 ;  extractive,  6.7. 

There  is  another  analysis  of  retained  menstrual  fluid  by  H.  Miiller 
in  Henle  and  Pfeuffer's  Zeitsch-ift,  1846. 

Sometimes  the  fluid  undergoes  decomposition,  and  then  gas  mixed 
with  the  blood  constitutes  physo-hsematometra. 

The  symptoms  of  atresia  are  those  which  might  be  expected  from  ob- 
structed functions.  "  Impediuntur  coitus,  conceptio,  et  purgatio."  Until 
the  advent  of  puberty,  nothing  may  cause  suspicion  of  abnormality. 
But  with  the  onset  of  menstruation  distress  begins,  due  to  retention  of 
the  menstrual  fluid ;  at  first,  perhaps,  this  is  limited  to  passing  attacks 
,of  uterine  colic,  marked  by  pelvic  pain  and  bearing  down  or  expulsive 


SYMPTOMS     OF    RETEXTION.  183 

efforts.  Vomiting  often  attends,  as  in  all  cases  where  the  uterine  fibre 
is  suddenly  stretched.  These  attacks,  more  or  less  periodical,  are  not 
attended  by  the  expected  appearance  of  the  menses.  Occasionally  there 
is  a  vicarious  discliarge  of  blood  in  form  of  epistaxis.  In  Fallen's  case, 
one  of  absence  of  the  vagina,  there  were  marked  menstrual  molimina, 
but  no  accumulation  of  menstrual  blood  in  the  uterus  or  neighborhood. 
When  an  artificial  vagina  Avas  made,  menstruation  took  place  periodi- 
cally by  this  channel,  and  the  epistaxis  ceased.  Gradually  the  distress 
increases.  A  sense  of  fulness  in  the  pelvis  arises ;  the  hypogastrium 
enlarges ;  the  abdomen  is  visibly  larger ;  perhaps  pregnancy  is  sus- 
pected ;  there  is  sometimes  retention  of  urine  from  the  pressure  of  the 
uterus  and  vagina  distended  with  the  accumulating  menstrual  secre- 
tions ;  defecation  is  difficult,  and  the  digestive  function  is  disturbed  ; 
irritating  fever,  with  a  sallow  skin,  and  vomiting — the  result  of  ab- 
sorption of  the  watery  part  of  the  confined  fluid — sets  in.  On  exami- 
nation, a  firm,  even  tumor  is  felt  rising  from  the  pelvis  behind  the  sym- 
physis pubis,  sometimes  as  high  as,  or  even  higher  than,  the  umbilicus. 

The  uterus  gradually  yields  under  excentric  pressure ;  as  in  preg- 
nancy, or  when  it  contains  a  growing  polypus,  it  then  grows,  its  mus- 
cular walls  as  well  as  its  cavity  enlarging.  This  process  meets  to  a 
certain  extent  the  pressure  of  the  accumulating  fluid  ;  but  the  contained 
matter  receiving  fresh  increments  at  every  menstrual  epoch,  after  a  time 
requires  more  space :  then  other  compensating  processes  bring  allevia- 
tion, and  stave  oflP  for  awhile  the  critical  moment  when  the  strain  can 
no  longer  be  borne.  The  more  watery  element. of  the  contained  fluid 
is  absorbed,  and  to  supplement  the  imperfect  distension  of  the  uterus, 
another  cavity  is  formed  by  the  distension  of  the  vagina ;  and  the  Fal- 
lopian tubes  stretching,  form  further  supplementary  receptacles ;  the 
uterine  and  vaginal  cavities  are  commonly  divided  by  a  strait  formed 
by  the  cervix  uteri. 

This  vaginal  pouch  may  be  very  large,  especially  if  the  occlusion 
exists  at  the  vulva,  when  it  may  so  compress  the  rectum  as  to  obstruct 
defecation  (Tiickwell),  or  the  bladder,  causing  retention  of  urine.  The 
obstruction  to  normal  menstruation  is  sometimes  compensated  by  men- 
strual deviation,  that  is  by  fluxes  from  the  intestines,  bladder,  nose, 
skin,  &c.  If  the  occlusion  exists  higher  up  the  vagina,  a  pouch  is  still 
formed.  And  it  is  remarlvable  that  the  vaginal  wall  undergoes  hyper- 
trophy in  the  same  way  as  the  uterine  wall.  In  a  fatal  case,  Dr.  Sutton 
{London  Hosp.  Reports,  1867)  found  the  vagina  so  much  hypertrophied 
that  the  walls  at  the  upper  part  were  quite. as  thick  as  the  uterine  pa- 
rietes.  Klob  contends  that  in  cases  of  obstruction  at  the  vulva,  it  is 
the  vagina  that  chiefly,  or  almost  exclusively,  forms  the  sac,  the  uterus 
scarcely  contributing.  This  is  certainly  not  always  true;  and  it  may 
be  doubted  whether  it  is  even  generally  so.  Dr.  Tuckwell's  case  (see 
Fig.  52)  exhibits  manifest  dilatation  of  both  uterus  and  vagina ;  and 
that  this  was  also  the  case  in  two  women  whom  I  relieved  by  opera- 
tion, I  had  distinct  evidence.  The  uterus  certa;inly  enlarges  considera- 
bly, and  the  easily  distensible  Fallopian  tubes  become  generally  dis- 
tended, forming  distinct  tumors,  readily  felt  on  either  side ;  sometimes, 
as  Bernutz  remarks,  mistaken  for  pelvic  phlegmons.     The  Fallopian 


184  EETENTION    OP    MENSTRUAL     FLUID. 

tubes  have  been  found  distended,  even  when  shut  off  from  the  uterine 
cavity ;  but  generally  the  uterine  orifices  of  the  tubes  are  expanded.  A 
further  stage  leads  to  the  escape  of  blood  from  the  Fallopian  tubes  at 
their  fimbriated  extremities,  or  through  rents  into  the  peritoneum.  This 
event,  long  ago  pointed  out  by  Brodie,  has  been  amply  confirmed  by 
subsequent  observers.  The  blood  collecting  in  Douglas's  pouch,  con- 
stitutes retro-uterine  hsematocele.  The  common  eifect  of  this  is  pelvic 
peritonitis,  sometimes  fatal,  at  others  resulting  in  segregation  of  the 
effused  blood  by  plastic  matter ;  a  later  stage  of  which  is  a  process  of 
suppuration  or  necrosis  of  the  posterior  vaginal  wall  and  possibly  dis- 
charge of  the  hsematocele  and  care.  As  Bernutz  says,  and  I  venture 
to  add  my  own  testimony  in  support,  the  foregoing  phenomena  of  ob- 
structed menstrual  flow  may  result  from  uterine  deviations,  especially 
flexions,  from  spasmodic  contraction  of  the  cervix  uteri,  and,  according 
to  my  own  observation,  from  congenital  narrowing  of  the  os  externum 
uteri  associated  with  a  conical  vaginal-portion.  The  symptoms  of  ab- 
dominal shock  and  peritonitis  following  upon  those  of  retention  of 
menses,  indicate  the  occurrence  of  effusion  of  blood  from  the  Fallopian 
tubes  into  the  peritoneum.  These  symptoms  depending  on  the  same 
accident  are  very  liable  to  follow  operations  for  the  discharge  of  the  re- 
tained fluid.  The  history  of  hsematocele  will  be  fully  discussed  here- 
after. A  tumor  is  formed,  sometimes  of  considerable  size,  in  Douglas's 
sac;  at  first,  this  is  soft,  fluctuating;  it  then  gets  harder  under  coagu- 
lation, and  the  effusion  of  plastic  matter  around  it ;  a  firm  tumor  may 
be  felt  rising  above  the  pubes,  even  to  the  umbilicus.  The  abdominal 
walls  can  be  made  to  glide  over  it ;  the  limit  of  the  tumor  may  be  de- 
fined by  percussion;  inferiorly  the  tumor  sinks  into  the  pelvis.  By  the 
vagina  we  find  the  tumor  pushing  forward  the  roof  and  posterior  wall 
of  this  canal,  shortening  it,  and  compressing  it  from  behind  forwards, 
so  that  the  finger  is  guided  to  the  os  uteri  driven  forwards  behind  the 
symphysis.  The  os  felt  in  this  position,  and  a  firm  rounded  mass  ex- 
tending behind  it,  has  been  mistaken  for  retroversion  of  the  enlarged 
womb,  and  this  the  more  readily,  because  retention  of  urine  has  often 
been  an  urgent  symptom. 

Sometimes  the  atresia,  especially  in  the  acquired  cases,  as  when  cica- 
tricial occlusion  takes  place  after  fevers,  sloughing  from  severe  labor,  or 
frorn  injury  by  instruments,  is  not  quite  complete.  There  may  remain 
a  narrow  fistulous  tract,  communicating  with  the  expanded  sac,  which 
receives  the  menstrual  collection,  and  which  affords  an  occasional,  but 
rarely  complete  relief  by  oozing.  Such  a  fistulous  tract  may  act  for  a 
long  time  as  a  sort  of  safety-valve,  by  which  extreme  tension  is  re- 
lieved. It  is  liable  to  complete  occlusion  at  times.  This  was  the  case 
in  the  following  typical  instance : 

Cicatricial  closure  of  the  Vagina  following  Labor  ;  at  first  partial,  then 
complete  retention  of  menstrual  fluid — Dysmenorrhea —  Operation — 
Care. 

In  January,  1867,  I  met  Mr.  Powell  at  Wey bridge,  in  the  case  of 
Mrs.  W.     Twelve  years  before,  she  had  been  delivered  by  instruments 


CASE.  185 

of  twins  after  severe  labor.  From  that  time  she  had  suffered  more  or 
less  difficulty  in  menstruation.  This  had  increased  gradually,  and 
in  a  marked  degree  during  the  last  two  years.  During  the  last  three 
months  her  condition  has  become  very  serious..  At  each  menstrual 
period,  severe  colic  with  expulsive  pains  set  in.  An  enlargement  has 
been  felt  rising  considerably  above  the  pubes.  Partial  relief  has  been 
obtained  by  the  escape  of  blood,  and  a  very  offensive  ichorous  dis- 
charge. At  times,  retention  of  urine  calling  for  the  use  of  the  catheter 
has  occurred.  The  introduction  of  the  catheter  was  difficult,  owing  to 
the  urethra  being  compressed  and  deviated  by  the  tumor.  A  period 
came  round  two  or  three  days  ago  with  increased  suffering  and  com- 
plete retention  of  menses.  The  enlargement  of  the  uterus  was  rapid ; 
it  rose  nearly  to  the  umbilicus  in  twelve  hours.  There  was  great  pros- 
tration and  small  pulse.  We  found  the  vagina  quite  occluded  by  con- 
tracted dense  cicatricial  tissue  extending  from  the  meatus  urinarius  to 
the  anus,  nothing  but  a  scarred  furrow  marking  the  site  of  the  vulva. 
There  was  a  minute  red  point  which  seemed  to  be  the  opening  of  a 
fistulous  tract;  but  not  even  a  small  probe  would  pass  into  it.  It  is 
probable  that  this  had  been  really  the  opening  of  a  fistula  which  had 
on  previous  occasions  given  difficult  and  partial  escape  to  the  accumu- 
lated fluids  above,  but  had  now  become  quite  closed.  I  determined  to 
try  and  open  up  the  vaginal  canal  next  day.  She  passed  a  bad  night 
from  severe  colic  and  efforts  at  expulsion;  and  on  the  following  morn- 
ing I  found  the  uterine  tumor  just  as  large  and  firm  as  before.  It  was 
directed  a  little  to  the  left.  It  was  also  felt  per  rectum,  at  a  point 
j)rojecting  within  the  pelvis.  The  patient  was  placed  in  lithotomy  po- 
sition. I  passed  a  flexible  male  catheter  into  the  bladder,  and  one 
finger  into  the  rectum.  I  could  then  feel  the  hard  dense  column  of  cica- 
tricial tissue  between  the  bladder  and  rectum,  which  represented  the 
obliterated  vagina.  I  then,  thus  guided,  made  careful  incisions  in  the 
cicatrix,  and  at  about  an  inch  above  the  outer  surface  struck  the  sac. 
A  quantity  of  offensive  ichor  mingled  with  dirty-white  clots  escaped. 
I  then  felt  a  small  dense  ring  at  the  bottom  of  my  incisions,  no  doubt 
the  upper  part  of  the  cicatrix.  This  I  enlarged  by  a  Simpson's  metro- 
tome and  a  fine  knife  until  I  could  pass  my  finger  through  it.  Then 
I  found  beyond  this  ring  a  widely-distended  pouch  formed  by  the 
dilated  fundus  of  the  vagina;  at  the  extremity  of  this  pouch  I  felt  the 
OS  uteri  slightly  open,  very  soft.  I  could  not  reach  into  the  uterus, 
but  it  was  clear  that  the  uterus  also  was  distended,  forming  the  supra- 
pubic tumor,  as  this  gradually  subsided  as  more  and  more  of  the  ichor- 
ous discharge  came  away.  The  patient  felt  great  relief.  A  compress 
and  bandage  being  applied  to  the  abdomen,  she  was  put  to  bed  com- 
fortable. Three  days  afterwards  I  had  a  letter  from  Mr.  Powell  say- 
ing "she  was  going  on  favorably;  did  not  suffer  much  pain;  the  dis- 
charge was  decreasing;  she  was  very  low;  the  catheter  was  used  night 
and  morning ;  no  sign  of  inflammation,  but  he  feared  pyaemia,  in 
fact  he  thought  she  had  been  for  some  time  past  suffering  from  it  to  a 
degree." 

It  was  my  intention  at  a  later  period  to  restore  the  vagina  more  com- 


186  EETENTION    FROM     ATRESIA. 

pletely;  but  the  patient  being  relieved,  refused  further  treatment.  She 
got  quite  well. 

The  following  case  illustrates  so  many  points  in  the  history  of  ob- 
structed menstruation  that  I  am  induced  to  relate  it : 

Mrs.  W has  been  married  three  years  without  becoming  preg- 
nant. She  is  well  developed  in  frame.  Two  years  ago  she  had  yellow 
fever  in  South  America.  Her  health  has  been  indiiferent  since  then. 
She  had  always  menstruated  regularly ;  at  times  in  advance  of  the 
period  due,  and  lasting  four  or  five  days ;  not  excessive  in  quantity. 
There  had  been  dysmenorrhoea  before  marriage  and  since,  but  not 
constantly.  But  latterly,  and  especially  since  the  fever,  the  dysmenor- 
rhoea has  been  very  severe,  and  has  evidently  undermined  her  health, 
and  wrought  a  serious  degree  of  despondency,  and  other  nervous 
symptoms. 

Under  these  circumstances  she  came  to  England  for  advice;  saw  two 
medical  men  in  town,  who  told  her  there  was  nothing  to  be  done.  She 
came  to  me  in  October  last,  very  discouraged,  but  determined  not  to 
go  back  to  South  America  until  she  was  either  relieved,  or  well  assured 
that  her  case  was  hopeless.  I  found  the  vagina  was  a  wide  shallow 
cul-de-sac,  not  an  inch  deep.  There  was  no  projecting  cervix  uteri, 
and  no  solid  body  in  the  roof  of  the  cul-de-sac  where  the  uterus 
might  be  expected  to  be  found.  About  the  middle  of  the  cul-de-sac, 
however,  was  a  small  round  hole,  which  just  admitted  the  point  of  the 
sound.  This  had  been  taken  to  be  the  os  uteri  externum.  The  case 
looked  unpromising,  as  no  uterus  could  be  felt  in  connection  with  it. 
I  submitted  her  to  further  examination  under  chloroform.  Then  hav- 
ing passed  a  sound  into  the  bladder  and  a  finger  into  the  rectum,  I  as- 
certained that  for  at  least  two  inches  above  the  vaginal  cul-de-sac  there 
was  no  uterus,  nothing  but  the  wall  of  the  rectum  and  the  wall  of  the 
bladder  intervened.  But  about  three  inches  beyond  the  anus  I  could 
feel  a  solid  rounded  mass,  which  I  concluded  to  be  the  uterus  retro- 
verted.  On  passing  the  sound  through  the  small  opening  in  the  vagi- 
nal cul-de-sac  I  found  it  proceeded  two  inches  along  the  septum,  be- 
tween the  bladder  and  the  rectum,  towards  the  solid  body  which  I 
believed  to  be  the  uterus.  I  was  now  therefore  in  a  position  to  con- 
clude that  there  was  atresia,  or  closing  of  the  vagina  from  a  little  above 
the  vulva  upwards  along  its  whole  extent.  I  am  unable  to  determine 
whether  this  obliteration  of  the  canal  was  congenital  or  acquired.  It 
may  possibly  have  been  a  sequel  of  the  fever  she  suffered  two  years 
before. 

The  position  of  things  being  recognized  by  Drs.  Avcling  and  Hewer, 
who  assisted  me  in  the  exploration,  I  determined  to  open  up  the  ob- 
literated tract  of  the  vagina  so  as  to  establish  a  free  communication 
with  the  body  above,  which  I  took  to  be  the  uterus.  This  was  done 
under  chloroform,  assisted  by  Dr.  Aveling  and  Dr.  Hewer  at  two  dif- 
ferent sittings  at  an  interval  of  a  month.  Starting  from  the  miiuite 
opening  in  the  vaginal  cul-de-sac,  I  separated  the  bladder  from  the 
rectum,  partly  by  incising,  partly  by  tearing  with  my  fingers  until  I 
could  fairly  touch  the  solid  body  through  the  new  canal.  When  this 
was  done  I  ascertained  that  this  body  was  tlie  uterus;  it  was  more 


ATRESIA    VAGIN.E. 


187 


rounded  than  natural,  its  fundus  was  directed  forwards  ;  it  was  the  cer- 
vix directed  backwards  which  was  felt  through  the  anterior  wall  of  the 
rectum.  It  was  now  clear  that  there  had  been  a  small  cavity  represent- 
ing the  upper  part  of  the  vagina,  into  which  the  cervix  uteri  opened ; 
that  this  small  cavity  was  closed  in  just  below  the  cervix  uteri  by  the 
fusion  of  the  vaginal  w^alls,  if  such  had  ever  existed ;  that  a  fine  devious 
fistulous  tract  ran  from  this  upper  vaginal  cavity  to  open  into  the  lower 
vaginal  cul-de-sac;  that  the  menstrual  discharge  had  with  great  dif- 
ficulty made  its  way  along  this  fistula,  wdiich  was  always  in  danger  of 
closing. 

I  have  endeavored  to  give  an  idea  of  the  state  of  the  parts  in  Fig. 
53. 

I  did  not  succeed  in  getting  a  sound  into  the  os  uteri ;  but  this  will 
probably  be  effected  at  some  future  time.  To  maintain  the  new  vagina 
I  have  applied  a  small  elongated  Hodge's  pessary,  the  upper  arch  of 


Fig  53 


Atresia  of  Vagina. 

R,  rectum  ;  b,  bladder;  L',  uterus;  v,  eul-de-sac  at  vulva;  a,  dense  tissue  in  place  of  vagina  traversed 

by  a  narrow  fistulous  tract  between  v  and  uterus. 

Avhich,  under  the  leverage  which  is  the  principle  of  the  action  of  this 
most  useful  instrument,  is  constantly  carried  high  up  into  the  restored 
vaginal  roof.     A  month  after  the  last  operation,  the  vagina  was  well 


188  ATRESIA    VAGINA. 

preserved,  and  examining  by  a  Fergusson's  speculum  during  a  period,  I 
could  see  the  menstrual  fluid  being  poured  into  the  summit  of  the 
vagina.  For  the  first  time  she  was  menstruating  without  pain,  and  her 
health  and  spirits  were  already  improved.  She  menstruated  healthily 
several  times  ;  her  health  was  fairly  restored.  But  I  believe  there  was 
at  a  later  period  some  disposition  to  contraction,  which  would  require 
another  operation. 

Dr.  Gardner^  cites  from  Professor  Meigs  "  a  case  of  unusual  form 
of  stricture  of  the  vagina,  which  was  the  cause  of  an  almost  fatal  error 
in  diagnosis."  The  figure  given  represents  the  uterus  of  normal  size, 
then  a  pouch  formed  by  the  dilated  vagina,  and  the  vagina  itself  nearly 
closed  about  its  middle  by  a  stricture  half  an  inch  long.  The  stricture 
was  traversed  by  an  extremely  narrow  fistula,  just  permitting  of  what 
has  been  called  "stillicidium  mensium." 

Professor  Thomas^  describes  a  similar  case.  There  was  this  "  stillici- 
dium  ;"  but  notwithstanding,  the  sac  of  the  vagina,  between  the  con- 
striction and  the  neck  of  the  uterus,  contained  several  ounces  of  thick 
tenacious  blood. 

Simpson  describes  "a  kind  of  adhesive  or  obliterative  vaginitis"  in 
adults,  differing  in  some  respects  from  the  adhesive  vaginitis  of  infants. 
In  infants  the  inflammatory  closure  is  usually  limited  to  the  orifice  of 
the  vagina,  and  produces  complete  occlusion.  In  adults  it  generally  com- 
mences at  the  upper  part  of  the  vagina,  sjd reads  gradually  downwards, 
and  seldom  produces  complete  occlusion.  It  is  almost  always  attended 
with  a  circumferential  contraction  of  the  canal  at  the  site  of  the  disease, 
so  that  when  it  is  limited,  as  it  often  is,  to  the  top  of  the  vagina,  the  os 
uteri  is  felt  drawn  up  to  the  apex  of  a  narrow  conical  or  funnel-shaped 
cavity.  But  it  occurs  without  this  circular  contraction,  says  Simpson; 
and  I  feel  justified  by  observation  in  affirming  that  this  funnel-shaped 
contraction  of  the  upper  part  of  the  vagina  may  occur  independently 
of  inflammation.  The  adhesion  is  more  agglutinative,  like  that  which 
unites  serous  surfaces  in  the  early  stages  of  inflammation,  than  true 
fusion.     The  finger  can  separate  the  adhering  surfaces. 

It  is  a  remarkable  circumstance  in  connection  Avith  the  history  of 
atresia,  or  absence  of  the  vagina,  where  no  uterus  can  be  found,  or  at 
least  only  such  a  rudimentary  one  as  to  be  incapable  of  performing  the 
functions  of  a  uterus,  that  the  artificial  formation  of  a  vagina  brings 
considerable  relief.  Of  this  I  have  seen  examples  ;  one  especially  was 
that  of  a  well-developed  young  lady,  who  had  suffered  from  what  may 
be  called  difficult  ovulation;  there  was  evidence  of  menstrual  molimina, 
but  there  Avas  no  discharge.  I  dissected  up  a  canal  between  the  rectum 
and  bladder ;  a  good  vagina  was  maintained  by  Avearing  a  Sims's  dilator 
or  a  Hodge's  pessary ;  and  she  recovered  health,  remaining  free  from 
pain,  and  married. 

This,  and  other  cases,  of  AA'hich  I  may  specify  that  of  a  young  AA'oman 
lately  under  my  care  in  St.  Thomas's  Hospital,  prove  that  ovarian  de- 
velopment may  be  good,  and  the  uterus  remain  undeveloped.  They 
also  prove  that  the  general  frame  may  be  AA^ell  de\^eloped,  notAA'ithstand- 

1  Gardner  on  "Sterility,"  New  York. 

*  "  Diseases  of  Women,"   Philadelphia,  1869. 


ATRESIA    VAGINA.  189 

ing  the  want  of  a  uterus,  and  that  the  evolution  of  the  general  system 
takes  its  stimulus  from  the  ovaries. 

Treatment. — In  the  case  of  apparent  absence  of  the  vagina  there  are 
three  methods  of  proceeding.  The  first  is  to  cut  a  channel  through  the 
tissues  between  the  urethra  and  the  rectum  up  to  the  uterus.  The 
second,  adopted  by  Fletcher  (icmcef,  1830-1831)  and  Araussat  {Gazette 
Medioale,  1835),  is  to  tear  or  stretch  out  a  canal  by  the  fingers  or  other 
dilating  instruments.  The  third  may  be  called  the  mixed  method, 
making  use  both  of  cutting  and  dilating.  The  last  combines  the  ad- 
vantages of  the  two  preceding,  and  at  the  same  time  reduces  their  dis- 
advantages. Whatever  mode  is  adopted,  the  patient  is  placed  in 
lithotomy  position,  the  space  between  the  urethra  and  rectum  is  care- 
fully examined,  the  index  of  the  left  hand  is  passed  into  the  rectum, 
the  sound  is  passed  into  the  bladder,  and  feeling  for  it  by  the  finger  in 
the  rectum,  the  amount  of  tissues  available  for  burrowing,  and  the 
position  of  the  uterine  tumor  are  determined.  Then  the  sound  is  held 
up  under  the  pubic  arch,  whilst  the  finger  carries  the  rectum  away  in 
the  opposite  direction.  A  transverse  incision  is  made  in  front  of  the 
anus  through  the  skin,  then  cautiously  nicking  with  the  knife  or  scissors 
and  stretching  out  with  the  fingers,  working  from  side  to  side,  between 
the  finger  in  rectum  and  the  sound  in  urethra  as  guides,  a  canal  is 
opened  to  the  uterus.  Care  should  be  taken  not  only  to  make  all  inci- 
sions laterally,  but  to  work  backwards  towards  the  rectum,  as  the  chief 
danger  is  that  of  penetrating  the  wall  of  the  bladder.  If  the  os  is  felt, 
a  sound  should  be  tried  first ;  if  the  os  be  impervious,  it  may  be  per- 
forated by  a  trocar  or  by  the  knife.  It  may  be  desirable  to  carry  out 
the  proceeding  at  different  sittings.  It  will  generally  be  necessary  to 
place  a  tent  or  bougie  in  the  uterine  opening  to  prevent  closure ;  and 
the  artificial  vagina  must  be  preserved  by  plugging  with  lint  steeped 
in  carbolic  acid  oil,  glycerin,  or  the  glass  or  vulcanite  dilator  of  Sims, 
or  what  I  have  found  to  answer  better,  a  narrow  Hodge-pessary.  The 
tendency  of  the  parts  to  contract  and  close  again  after  operations  for 
the  restoration  or  formation  of  a  vagina  is  very  great.  The  operation 
may  have  to  be  repeated,  unless  great  care  is  taken  to  preserve  patency 
by  artificial  means.  But  I  have  known  a  good  vagina  to  be  maintained 
for  a  year  after  operation,  when  the  subject  married,  and  there  was  no 
further  trouble. 

Where  the  closure  of  the  vagina  is  the  result  of  cicatrices  from 
sloughs,  the  same  cautious  mode  of  dissecting  and  dilating  may  be 
adopted.  Where  the  vaginal  canal  exists,  and  there  is  closure  of  the 
vulva  by  agglutination  of  the  nymphse,  or  from  imperforate  hymen, 
the  preponderance  of  testimony  is  in  favor  of  making  an  opening  into 
the  vagina.  The  distended  fluctuating  membrane  indicates  the  spot. 
This  is  pierced  by  a  trocar,  or  better  by  a  knife. 

It  has  frequently  been  discussed  how  the  catastrophe  of  sudden  escape 
of  the  retained  fluid  into  the  peritoneal  cavity  can  best  be  averted. 
Some  have  contended  that  it  is  better  to  make  a  very  small  opening  in 
the  hymen  and  let  the  fluid  drain  away  gradually,  hoping  that  in  this 
way  the  suddenness  of  the  collapse  of  the  uterus  might  be  diminished. 
This  is  the  plan  I  have  hitherto  followed.     But  others  have  preferred 


190  IMPERFORATE     HYMEN. 

making  a  free  incision  at  once,  and  even  proceeding  to  wash  out  the 
cavity.  I  am  not  sure  that  this  is  not  the  best  plan.  A  free  external 
outlet  would  make  it  easier  for  the  contracting  uterus  to  expel  its  con- 
tents by  this  route,  and  thus  take  off  the  pressure  towards  the  tubes. 
On  the  other  hand,  the  rapid  retreat  of  the  uterus  would  favor  lacera- 
tion of  the  tubes,  if  held  back  by  adhesion.  The  balance  of  advan- 
tages and  of  drawbacks  of  either  plan  is  difficult  to  strike ;  and  it  is 
to  be  apprehended  that  cases  will  continue  to  occur  in  which  a  fatal 
result  will  follow  any  method  of  treatment. 

A  plan  which  I  should  be  disposed  to  try  is  to  draw  off*  a  little  at  a 
time  by  the  aspirator-trocar,  so  as  to  effect  a  very  gradual  diminution 
of  the  cavity  before  finally  freely  dividing  the  obstruction.  In  any 
case  absolute  rest  should  be  rigidly  enforced.  On  no  consideration 
should  even  simple  puncture  of  an  imperforate  hymen  be  done  in  the 
consulting-room.  The  patient  should  be  in  bed,  and  keej)  her  bed  until 
the  discharge  has  fairly  ceased,  and  the  disturbed  uterus  and  vagina 
have  assumed  a  natural  condition. 

It  is  held  that  these  dangers  are  lessened  by  letting  the  blood  ooze 
out  very  slowly.  The  fact  is  that  death  has  followed  both  methods ; 
and  we  are  perhaps  not  yet  in  possession  of  certain  means  of  rendering 
even  the  simplest  puncture  perfectly  safe.  I  believe  the  opening  should 
be  sufficiently  large  to  admit  of  easy  evacuation,  and  that  to  prevent 
the  entry  of  air  a  compress  should  be  applied  over  the  uterus  and  sus- 
tained by  moderate  pressure  with  a  bandage.  In  some  cases  injections 
of  warm  water  have  been  used  to  wash  out  the  uterus.  It  is  doubtful 
whether  this  is  good  practice  at  the  time  of  the  operation,  but  if  there 
should  arise  decomposition,  the  gentle  injection  of  a  weak  solution  of 
permanganate  of  potash  or  carbolic  acid  will  be  desirable.  After  a  few 
days  it  is  proper  to  enlarge  the  opening  in  the  vulva  by  removing  a 
circular  piece  of  the  membrane,  so  as  to  fit  the  parts  for  all  their  func- 
tions. Absolute  rest  in  bed  for  some  days  is  a  wise  precaution,  not- 
withstanding the  histories  of  cases  where  impunity  has  followed  its 
neglect.  Symptoms  of  peritonitis,  indicating  that  retained  fluid  has 
suddenly  escaped  into  the  peritoneal  cavity,  have  set  in  on  the  third  or 
fourth  day.  The  contraction  of  the  uterus  leading  to  this  catastrophe 
does  not  take  place  immediately  after  the  operation.  The  greatest  care, 
therefore,  is  necessary  for  some  days  afterwards. 

Dr.  Ramsbotham  collected  several  cases  in  which  simple  puncture 
of  imperforate  hymen  terminated  fatally.  Simpson  relates  a  case  of 
occlusion  of  the  vagina  from  adhesion  causing  a  septum  of  no  great 
thickness.  Retention  of  menstrual  fluid  was  going  on,  so  a  very  small 
incision  was  made ;  the  patient  remained  well  for  two  or  three  days, 
great  quantities  of  the  usual  dark  grumous  fluid  constantly  escaping  by 
the  vagina.  On  the  third  day  surgical  fever  set  in,  and  in  a  few  days 
she  died.  The  autopsy  showed  that  the  interior  of  the  distended  uterus 
had  become  the  seat  of  a  very  intense  inflammation,  which  had  spread 
thence,  and  led  to  a  severe  and  fatal  peritonitis.  This  was  probably 
set  up  by  air  getting  into  the  uterus  and  causing  decomposition  and 
septicaemia.  It  strengthens  the  argument  for  free  incision  and  washing 
out  the  uterus. 


DILATATION    OF    FALLOPIAN    TUBES.  191 

In  cases  of  occlusion  of  the  uterus  with  retention  of  menses,  the  in- 
dication is  to  make  a  passage  into  tlie  cavity.  This  may  be  clone  by  a 
trocar  or  by  a  bistoury.  The  fluid  evacuated,  it  is  necessary  to  intro- 
duce a  tent — a  metallic  one  is  best — to  preserve  the  opening,  which 
would  otherwise  close,  and  lead  to  a  repetition  of  the  mischief.  This 
liability  is  especially  great  in  cases  of  contraction  after  amputation  of 
the  neck.  Lefort  cites,  however,  several  instances  where  death  followed 
the  simple  evacuation  by  puncture. 

The  opening  into  the  uterus  is  best  made  by  a  fine-pointed  knife. 
After  piercing  in  the  central  point,  the  natural  seat  of  the  os  uteri,  in- 
cisions may  be  made  on  either  side,  and  by  carefully  dissecting  upwards, 
a  passage  is  made  into  the  cavity  of  the  uterus. 

Some  have  advised  puncturing  by  the  rectum  in  preference,  and  even 
puncture  of  the  uterus  above  the  symphysis  pubis  has  been  recom- 
mended. The  experience  of  puncture  of  the  rectum  is  not  so  favora- 
ble as  to  show  any  superiority  over  opening  by  the  vagina.  It  is  an 
imperfect  operation,  for  the  establishment  of  a  vaginal  canal  would  still 
be  indicated  when  relief  from  hsematometra  has  been  obtained.  In 
cases  where  opening  up  the  natural  route  is  impracticable  or  too  haz- 
ardous, it  may  be  resorted  to  as  a  temporary  expedient.  Fatal  peri- 
tonitis followed  in  cases  treated  in  this  way  by  Antoine  Dubois  and 
Dupuytren. 

Dr.  Oldham  {Gkiy's  Re-ports,  1857)  reports  two  cases  in  which  punc- 
ture per  rectum  was  practiced.  In  one  there  was  congenital  absence  of 
vagina ;  the  os  uteri  was  felt  through  the  rectum,  the  trocar  was  made 
to  pierce  at  this  point.  The  operation  was  repeated  on  four  occasions ; 
at  last  the  opening  continued  patent,  and  menstruation  took  place  by 
the  rectum.  In  the  other  case  the  vagina  was  closed  by  dense  cicatrix ; 
the  OS  uteri  was  felt  by  rectum,  and  was  punctured;  relief  followed.  A 
third  case  at  Guy's  is  reported  by  Dr.  Hicks  (Iledical  Times  and  Gazette, 
1861 ) :  here  there  was  absence  of  vagina  ;  puncture  by  rectum  was  fol- 
lowed by  relief,  and,  as  far  as  the  report  goes,  there  was  subsequent 
amenorrhoea. 

In  striking  for  the  os  uteri  by  the  vagina  it  is  very  possible  to  pierce 
the  rectum  behind  the  cervix.  In  such  a  case  menstruation  has  thence- 
forward occurred  per  rectum. 

The  time  selected  for  the  operation  should  be  remote  from  the  men- 
strual epochs ;  during  the  epochs  the  uterus  is  more  apt  to  resent 
interference. 

.  When  these  cases  of  retention  have  been  relieved,  and  have  ap- 
parently recovered,  it  must  be  remembered  that  the  Fallopian  tubes 
do  not  at  once,  perhaps  not  for  a  long  time,  recover  their  normal  calibre. 
Some  degree  of  abnormal  dilatation  remains.  This  is  certainly  the  case 
in  the  partial  retention  due  to  stenosis  of  the  cervix  and  to  retroflexion. 
The  knowledge  of  this  fact  is  of  the  highest  importance  in  practice. 
The  long-continued  obstruction  having  entailed  dilatation  of  the  uter- 
ine cavity,  and  catarrh  of  its  mucous  membrane,  with  very  often  a 
disposition  to  metrorrhagia,  the  physician  is  tempted  to  inject  astrin- 
gent fluids  into  the  uterus.  It  is  well  known  that  fatal  accidents  have 
followed  this  practice,  and  much  discussion  has  taken  place  as  to  the 


192  DYSMENORRHCEA. 

immediate  cause  of  these  accidents.  The  prevailing  idea  is  that  the 
injected  fluid  is  driven  along  the  tubes  by  the  force  of  the  syringe,  its 
return  by  the  cervix  being  stopped  by  the  injecting-tube  which  fills  it. 
I  am  disposed  to  believe  that  where  there  is  unusual  patency  of  the 
Fallopian  tubes,  this  may  occasionally  be  the  case.  But  the  more 
common  mechanism,  I  am  convinced,  is  that  which  I  have  just  ex- 
plained as  occurring  in  retention  from  imperforate  hymen.  The  as- 
tringent fluid  thrown  into  the  uterine  cavity  acts  primarily  as  an 
irritant  and  constringent.  This  action  is  forcible  and  rapid.  The 
cavity  instantly  contracts  and  pumps  on  the  fluid  along  the  patent 
Fallopian  tubes.  That  this  was  what  occurred  in  a  case  in  which  a 
solution  of  perchloride  of  iron  was  injected  into  the  uterus,  on  account 
of  hemorrhage  from  retroflected  uterus,  in  the  London  Hospital,  seems 
to  me  beyond  doubt.  The  tubes  were  found  patulous,  and  fluid  had 
run  along  them  into  the  peritoneal  cavity. 

It  is  important  then  to  recognize  it  as  a  general  fact,  that  whenso- 
ever the  uterus  has  long  been  subjected  to  stenosis  or  flexion,  there 
will  very  probably  be  patency  of  the  Fallopian  tubes,  and,  conse- 
quently, facility  for  the  transmission  of  fluids  from  the  uterine  cavity 
into  the  peritoneal  sac. 


CHAPTER  XX. 

DYSMENOERHCEA— NETTEALGIC;    CONGESTIVE;   FROM 
OBSTRUCTED  EXCRETION;  INFLAMMATORY. 

Dysmenorrhcea  is  the  term  used  to  express  that  menstruation  is 
performed  with  difficulty  and  pain.  It  is  a  very  frequent  affection, 
being  symptomatic  of,  or  consequent  upon  a  great  variety  of  morbid 
conditions.  These  morbid  conditions  of  course  are  mostly  unknown 
to  the  patient ;  she  applies  for  relief  of  the  functional  distress.  To 
give  the  sought-for  relief  the  physician  must  form  a  clear  idea  of  the 
causes  of  the  distress.  The  method  by  Avhich  this  knowledge  is  ar- 
rived at  is  partly  by  clinical  observation  and  study  of  the  phenomena 
which  present  themselves,  and  of  the  condition  of  the  organs  involved ; 
and  partly  by  observation  of  the  effects  of  treatment.  It  may  be  ad- 
mitted that  the  means  of  treatment  employed  are  sometimes  empirical ; 
that  is,  they  are  not  directed  by  a  clear  comprehension  of  the  cause  of 
the  distress ;  but  if  we  find  that  these  means  are  frequently  followed 
by  success,  this  treatment,  empirical  though  it  be  at  first,  will  lead  us 


DYSMENOREHCEA.  193 

to  a  clearer  knowledge  of  the  evil  which  it  overcame,  and  thus  in  the 
end  it  becomes  rational. 

By  this  double  process  we  arrive  at  the  conclusion  that  cases  of  dys- 
menorrhoea  may  be  classified  under  the  following  heads :  namely,  1. 
Neuralgic,  or  sympathetic.  2.  Congestive,  or  inflammatory.  3.  Me- 
chanical anomalies  of  the  uterus.  4.  Fallopian  obstruction.  5. 
Ovarian  disorder,  constituting  a  distinct  form  of  dysmenorrhoea. 

The  simple  study  of  the  subjective  phenomena  will  not  enable  us  to 
distinguish  cases  of  one  kind  from  those  of  another  kind.  Indeed,  so 
long  as  this  very  imperfect  method  was  exclusively  pursued,  all  cases 
of  dysmenorrhoea  were  confounded  together,  or  the  distinctions  made 
were  necessarily  arbitrary  and  fanciful,  and  treatment,  being  aimed  at 
random,  was  generally  unsuccessful.  This  is  a  logical  necessity.  For 
the  practitioner  who  limits  his  observation  to  the  subjective  symptoms 
must  perforce  exclude  from  his  resources  those  means  which  are  sug- 
gested by  the  objective  method  of  investigation.  Not  many  years  ago, 
dysmenorrhoea  was  almost  universally  looked  upon  and  treated  as  a 
nervous  affection  of  the  uterus  itself,  or  sympathetic  with  disorders  of 
distant  organs,  or  the  expression  of  constitutional  debility.  And 
vague  ideas  of  this  kind  still  largely  prevail  amongst  physicians  who 
have  not  directed  particular  attention  to  the  pathology  of  the  ovaries 
and  uterus.  But  in  proportion  as  precise  objective  methods  of  investi- 
gation have  been  applied  to  the  study,  it  has  been  discovered  that  in 
most  cases  the  nervous  phenomena  are  dependent  upon  distinct  morbid 
conditions  of  the  uterine  tissue,  or  upon  conditions  which  oppose  a  me- 
chanical obstacle  to  the  proper  performance  of  the  uterine  function,  or 
upon  disorder  of  the  ovary. 

If,  therefore,  we  still  retain  the  term  neuralgic  dysmenorrhoea,  we 
must  do  so  on  the  understanding,  that  although  expressing  a  really 
existing  disorder,  it  is  a  convenient  asylum  ignorantioi,  under  which  we 
may  class  a  number  of  cases,  the  true  pathology  of  which  eludes  our 
research.  Extending  observation  Avill,  however,  certainly  contract  this 
asylum  more  and  more,  if  indeed  we  may  not  hope  to  close  it  altogether. 
We  may  see  a  remarkable  illustration  of  this  in  the  history  of  what 
that  admirable  clinical  physician.  Dr.  Gooch,  called  the  '^  irritable 
uterus."  The  late  Dr.  Robert  Ferguson,  commenting  on  Gooch's  de- 
scription,^ said :  "  This  malady,  I  believe,  is  deeply  rooted  in  the  very 
essence  of  that  complex  organic  function  termed  the  generative;  which, 
in  its  most  comprehensive  sense,  includes  no  inconsiderable  portion  of 
the  moral,  as  well  as  of  the  physical  development  of  the  female  orga- 
nization." Ferguson  recognized,  it  is  true,  the  fact  that  various  morbid 
conditions  of  the  uterus  and  ovaries  were  sometimes  associated  with  the 
so-called  irritable  uterus.  He  says  there  is  a  form  of  the  disease  not 
described  by  Gooch.  "  In  this  the  purely  nervous  aspect  of  the  malady 
is  masked  by  some  obvious  change  in  the  uterus  and  its  appendages;  but 
this  change  is  by  no  means  a  constant  one,  either  in  its  seat,  extent,  or 
nature.  Sometimes  there  is  a  congested  condition  of  the  uterus,  alter- 
ing its  shape  into  that  of  a  retort ;  the  enlarged  and  curved  fundus 

1  Prefatory  Essay  to  New  Sydenham  Society's  Edition  of  Gooch's  Works,  1859. 

13 


194  DYSMENORRHQEA. 

being  exquisitely  sensitive  of  pressure.  At  other  times  the  cervix  or 
some  portion  of  the  uterine  walls  is  the  seat  of  congestion,  of  varying 

consistency^  and  of  pain The  local  changes  have  been  the 

fluctuating,  the  nervous  affection  the  constant  element ;  in  it,  therefore, 
and  in  no  doctrine  of  a  phlogistic  origin,  can  I  place  the  essence  of  this 
strange  disease." 

Dr.  West  included'  these  cases  under  the  "  congestive  "  order ;  Dr. 
Henry  Bennet  assigned  inflammation  as  the  real  pathological  condition ; 
Dr.  Rigby  thought  many  cases  were  due  to  a  rheumatic  diathesis ;  and 
other  authors  have  from  time  to  time,  impelled  by  the  accidental  nature 
of  their  experience,  or  the  bent  which  preconceived  theories  had  im- 
parted to  their  observations,  given  prominent  or  exclusive  importance 
to  some  other  complication.  If  we  postpone  theory,  and  carefully 
analyze  a  large  number  of  cases,  noting  the  complications  and  the  effects 
of  treatment,  we  shall  find  that  the  cases  of  "  irritable  uterus  "  resolve 
themselves  into  the  following  groups,  viz. :  1.  In  which  there  is  mani- 
fest enlargement  from  congestion  of  the  uterus ;  2.  Subinvolution  with 
chronic  inflammation  of  the  uterus,  following  labor  or  abortion;  3. 
Reclination  or  flexion  of  the  uterus,  most  frequently  retroflexion ;  4.  A 
projecting  conical  vaginal-portion,  with  very  small  os  externum  uteri ; 
5.  Lateral  reclination,  mostly  associated  with  imperfect  development 
of  the  uterus;  6.  Disorder  of  distant  organs,  especially  of  the  digestive 
organs,  attended  or  not  by  one  or  more  of  the  preceding  structural 
faults,  and  almost  always  with  impaired  sanguification  and  nutrition ; 
7.  A  morbid  condition  of  the  ovaries ;  lastly,  a  residuum  of  cases  in 
which,  whether  from  not  pushing  investigation  to  the  proper  point  to 
discover  the  associated  fault,  or  because  there  really  is  no  physical  fault, 
we  are  obliged  to  conclude  that  the  dysmenorrhoea  is  simply  the  ex- 
pression of  nervous  disorder.  We  may  reasonably  expect  that  advanc- 
ing knoM^ledge  of  uterine  and  ovarian  pathology  will  still  further 
diminish  this  residuum. 

The  truth  is,  that  difficult  menstruation  so  exhausts  the  tone  of  the 
nervous  centres,  that  general  or  local  hyper^esthesia  is  almost  certain  to 
follow.  Many  women  complain  of  a  distressingly  exaggerated  sensi- 
tiveness all  over  the  skin.  In  some,  it  takes  the  form  of  neuralgia  of 
the  face  and  breasts;  in  some,  the  seat  is  in  the  uterus,  vagina,  or  vulva. 

I  think  observation  warrants  this  general  conclusion :  The  healthy, 
well-formed  uterus  is  rarely  an  "  irritable  uterus,"  or  associated  with 
dysmenorrhoea.  Or  the  case  may  be  stated  as  follows :  For  menstrua- 
tfon  to  occur  healthily  and  easily,  the  genital  canal  from  its  commence- 
ment at  the  fimbriated  extremity  of  the  Fallopian  tubes  to  the  vulva, 
must  be  pervious. 

This  presumed  purely  neuralgic  dysmenorrhoea  we  will  now  endeavor 
to  describe.  If  we  follow  a  chronological  order,  and  consider  first  the 
dysmenorrhoea,  which  is  observed  at  the  very  outset  of  the  function,  we 
find  a  number  of  cases  from  which  we  may  fairly  exclude  the  idea  of 
inflammatory  ulceration  or  other  tissue  disease,  since  these  conditions 
very  rarely  occur  in  early  girlhood.     The  reverence  due  to  youth,  and 


1  "Diseases  of  Women,"  3d  edition. 


NEURALGIC.  195 

pre-eminently  to  female  youth,  imperatively  forbids  physical  examina- 
tion, unless  under  urgent  circumstances  and  the  failure  of  ordinary 
treatment.  We  are,  therefore,  precluded  in  most  of  these  cases  from 
determining  in  the  first  instance  the  presence  or  absence  of  uterine 
flexions  and  narrowness  of  the  os  uteri,  which  are,  perhaps,  the  most 
frequent  causes  of  primitive  or  initial  dysmenorrhoea.  Whether  the 
pain  be  due  to  recognizable  mechanical  conditions  or  not,  the  phe- 
nomena observed  are  nearly  the  same.  The  disorder  may  be  associated 
with  an  hysterical  disposition ;  it  is  generally  associated  with  a  highly 
susceptible  nervous  temperament,  which  may  be  defined  as  the  hyperses- 
thetic  temperament.  Extreme  susceptibility  to  pain  is  one  of  the 
penalties  of  high  civilization,  and  of  too  luxurious  rearing.  Hence 
the  neuralgic  dysmenorrhoea  chiefly  affects  the  easier  classes.  It  is  not 
common,  I  believe,  amongst  the  laboring  agricultural  population ;  but 
it  is  by  no  means  infrequent  in  towns,  where,  although  girls  and  women 
may  have  to  work  for  a  living,  they  are  nevertheless  exposed  to  many 
enervating  influences,  hygienic  and  moral. 

The  first  onset  of  menstruation  is  generally  late ;  it  is  marked  by  pain 
coming  on  a  day  or  two  before  the  flow,  sometimes  so  intense  that  the 
sufferer  writhes  upon  the  floor,  and  is  compelled  to  take  to  bed.  The 
pain  begins  in  the  pelvic  region,  radiates  to  one  or  both  groins,  and 
shoots  down  the  legs.  It  is  commonly  paroxysmal,  resembling  colic — it 
is,  in  fact,  uterine  colic.  It  is  often  likened  to  labor.  Often  the  whole 
abdominal  surface  is  tender  to  the  touch.  At  times  it  simulates  peri- 
tonitis. This  pelvic  eccentric  irritation,  commonly  involving,  as  it 
does,  ovarian  irritation,  propagated  to  the  nervous  centres,  may  evoke 
other  nervous  phenomena,  as  hysteria,  vomiting,  hiccough,  headache, 
even  delirium,  and  in  some  cases,  mania.  The  urgent  symptoms  sub- 
side in  two  or  three  days ;  the  patient  recovers  so  much  strength  as  to 
enable  her  to  resume  her  ordinary  mode  of  life.  But  as  the  period  comes 
round  the  same  series  of  painful  phenomena  is  renewed. 

The  pain  is  often  diminished  when  the  flow  sets  in,  but  it  generally 
attends  the  whole  period  with  more  or  less  severity.  It  does  not  appear 
to  bear  any  constant  relation  to  the  amount  of  the  discharge ;  but  when 
this  is  so  great  as  to  deserve  the  name  of  menorrhagia,  we  may,  I  think, 
generally  predicate  with  confidence  the  coexistence  of  a  mechanical  dif- 
ficulty. If  there  is  no  recognized  organic  change  in  the  uterus,  or  dis- 
placement in  the  first  instance,  we  may  be  very  certain  that  some  com- 
plication of  the  kind  will  appear  sooner  or  later.  I  quite  coincide  in 
the  statement  of  Scanzoni,'  that  long-standing  dysmenorrhoea  rarely 
fails  to  induce  some  change  of  tissue  in  the  uterus,  the  most  common 
being  hyperplastic  enlargement. 

The  nervous  phenomena  described  may  attend  all  the  forms  of  dys- 
menorrhoea. We  are  thus  led  to  ask,  is  there  any  physical  condition  of 
the  organs  concerned  that  can  account  for  the  pain  ?  The  colic,  the  spas- 
modic character  of  the  pain,  seems  to  indicate  a  contracting  uterus  seek- 
ing to  expel  contents  that  irritate  it ;  and  this  is  often  true.  Bat  not 
always.     It  is  a  well-recognized  character  of  the  nervous  function  that 

1  Bcitrage,  1870. 


196  DYSMENORRHCEA. 

its  phenomena,  or  actions,  have  a  tendency  to  periodicity,  as  if,  like  elec- 
tricity, it  required  a  certain  degree  of  accumulation  of  the  vis  nervosa 
before  it  can  act.  So  in  the  case  of  pain  we  often  see  alternations  of  acme 
and  of  ease,  of  discharge  and  accumulation.  The  fact  that  the  period  of 
most  intense  pain  is  usually  twenty-four  hours  before  the  appearance  of 
blood,  is  held  to  prove  that  these  uterine  colics  or  paroxysms  cannot  be 
due  to  anything  contained  in  the  uterus,  and  irritating  it  to  contract. 
This  objection  rests  upon  the  assumption  that  there  is  nothing  but 
blood,  fluid  or  coagulated,  that  can  be  there.  But  this  is  overlooked, — 
the  ra]3id  preliminary  development  of  the  mucous  membrane  into  men- 
strual decidua,  the  congestion  of  this  structure,  and  of  the  uterus  gen- 
erally. This  is  enough  to  cause  tension  of  the  uterine  muscular  fibre, 
and  to  excite  it  to  contract,  and  this  swelling  of  the  mucous  and  muscu- 
lar walls  may  close  the  os  internum,  and  lead  to  partial  retention  when 
the  flow  begins.  The  frequent  vomiting  at  this  stage  favors  this  view. 
At  the  same  time,  there  is  the  ovarian  pain ;  and  to  this  the  hysterical 
symptoms  are  most  commonly  due. 

The  course  and  prognosis  of  neuralgic  dysmenorrhoea. — The  obsti- 
nate character  of  the  affection  is  well  known.  It  may  be  predicated 
with  some  confidence  that  a  girl  who  starts  with  dysmenorrhoea  is 
doomed  to  suifer  for  years,  perhaps  for  life.  It  is  said  sometimes  to  wear 
itself  but ;  occasionally  marriage,  if  fruitful,  brings  relief;  but  more 
frequently  the  recurring  attacks  of  pain,  even  if  unattended  by  other 
causes  of  distress,  increase  the  irritability  of  the  nervous  centres,  impair 
nutrition,  destroy  the  harmony  or  correlation  of  the  vital  forces,  and 
reduce  the  sufferer  to  the  condition  of  a  perpetual  invalid,  enjoying  at 
the  best,  only  comparative  remissions  of  illness.  If  pain  do  not  persist 
throughout  the  intermenstrual  intervals,  it  is  liable  to  be  evoked  by 
any  fatigue  or  emotion,  so  that  the  state  of  the  patient  comes  to  be  the 
chief  care  of  the  household. 

After  a  time,  as  R.  Ferguson,  who  draws  the  most  terrible,  but  not 
exaggerated  picture  of  the  affection,  observes,  the  erotic  element  is  in 
most  cases  entirely  extinguished.  "  All  intercourse  is  dreaded  or  loathed, 
at  the  very  instant  wdien  the  victim  under  the  passion  for  sympathetic 
commiseration  is  ready  to  give  up  her  whole  soul  to  the  first  acquain- 
tance, nurse,  or  practitioner  who  will  listen  and  pity.  They  who  have 
been  able  to  watch  this  real  and  most  formidable  malady  through  years 
have  many  a  tale  to  tell — of  husbands  estranged,  chiklren  neglected, 
and  home  stripped  of  all  its  holiest  influences,  authority  delegated  to 
strangers  and  abused,  ill-assorted  marriages,  expenditure  stretched  for 
health's  sake  to  its  extreme  limits."  Under  the  goading  of  repeated 
agony  the  occasional  resort  to  stimulants  merges  into  a  confrmed  habit 
of  drinking. 

Happily  the  recent  application  of  means  of  exploring  the  state  of 
the  organs  primarily  affected  has,  by  enabling  us  to  analyze  the  cases, 
shown  that  the  majority  at  least  are  dependent  upon  physical  causes 
which  admit  of  remedy.  The  treatment  has  become  far  more  success- 
ful than  was  contemplated  as  possible  by  Gooch  and  Ferguson.  The 
first  condition  in  which  we  are  likely  to  be  consulted  is  during  the 
attack.     We  are  called  upon,  as  our  first  duty,  to  relieve  pain ;  and 


NEURALGIC.  197 

during  the  menstrual  flow  our  liands  are  commonly  tied.  We  are 
driven  to  a  trial  of  sedatives  and  narcotics.  Where  the  agony  is  so 
intense  as  to  induce  delirium,  it  is  justifiable  to  induce  anaesthesia  by 
chloroform  or  chloral,  but  the  frequent  recourse  to  these  agents  is  apt 
to  entail  a  terrible  penalty.  The  patient  who  has  once  or  oftener  thus 
drowned  her  sufferings,  is  little  able  to  resist  the  imperious  craving  to 
throw  herself  into  the  same  treacherous  oblivion  on  every  return  of 
pain.  She  soon  falls  into  the  habit  of  exaggerating  her  suffering  so  as 
to  impose  upon  others,  as  well  as  herself,  the  necessity  of  getting  relief 
even  momentary  at  any  cost.  To  say  nothing  of  the  fatal  accidents 
which  have  occurred  from  the  use  or  abuse  of  chloroform  or  chloral, 
even  when  skilfully  administered,  experience  shows,  it  is  said,  that  the 
repeated  or  habitual  use  of  these  agents  is  liable  to  induce  epilepsy  and 
mental  prostration  of  a  kind  to  justify  apprehension  of  lapsing  into 
dementia.  There  is  no  principle  of  conduct  more  imperative  than  this  : 
so  to  direct  our  treatment  as  to  preserve  and  encourage  to  the  utmost 
the  mental  and  moral  integrity  of  the  patient.  When  once  we  have 
lost  the  aid  of  her  own  will,  when  she  has  lost  the  precious  gift  of  self- 
control,  our  task  is  a  sad  one.  We  are  almost  driven  into  becoming 
quasi-accomplices  in  a  course  that  almost  infallibly  ends  in  moral  anni- 
hilation, compared  with  which  the  original  malady,  still  subsisting, 
sinks  into  insignificance. 

One  of  the  best  temporary  sedatives  is  Hoffman's  anodyne,  the 
spiritus  setheris  sulphuricus  compositus,  which  may  be  given  in  half- 
drachm  doses.  To  this  may  be  added  tenor  fifteen  drops  of  liquor  opii 
sedativus,  and  both  act  better  if  given  with  liquor  ammonise  acetatis. 
Indian  hemp  in  half-grain  or  grain  doses  is  often  valuable ;  it  may  be 
given  alone  or  combined  in  pills  with  lupulin,  or  five  grains  of  Dover's 
powder.  Where  there  is  a  distinct  hysterical  character,  musk,  cam- 
phor, and  assafoetida  are  often  useful.  Allied  to  sedatives  in  their 
effects  are  the  bromides  of  potassium  and  ammonium.  One  or  other 
of  these  may  be  given  in  scruple  or  even  half-drachm  doses,  repeated 
every  four  or  six  hours.  Bromine  seems  to  possess  a  specific  power  in 
subduing  ovarian  excitation.  If  sedatives  cannot  be  taken  by  the 
mouth,  we  may  resort  to  subcutaneous  injection  of  one-eighth  or  one- 
sixth  of  a  grain  of  acetate  of  morphia;  or  half  a  drachm  of  laudanum 
may  be  thrown  into  the  rectum ;  or  medicated  pessaries  containing 
opium  or  belladonna  may  be  placed  in  the  rectum  or  vagina. 

The  local  treatment  in  the  purely  neuralgic  affection  is  restricted  to 
the  use  of  hot  fomentations  or  cataplasms  to  the  abdomen,  foot-baths, 
and  other  external  applications.  Simpson  recommended  the  injection 
of  chloroform  vapor  or  carbonic  acid  gas  into  the  vagina,  or  the  appli- 
cation of  a  small  bit  of  lint  soaked  in  chloroform  and  covered  with  a 
watch-glass  over  each  groin.  This  produces  a  small  blister.  The  diet 
should  be  simple,  and  the  use  of  stimulants  strictly  regulated. 

Moral  treatment  is  of  great  importance.  During  the  intervals  great 
care  should  be  taken  to  cultivate  habits  of  industry.  Occupation,  phys- 
ical and  mental,  is  the  great  panacea.  "  Something  to  do !"  is  the 
great  female  cry.     In  no  case  is  it  more  urgent  than  here. 

If  these  and  other  similar  means,  as  well  as  Time,  fail  to  bring  re- 


198  DYSMENORRHCEA. 

lief,  a  physical  examination  becomes  necessary,  and  then  we  shall  prob- 
ably discover  some  condition  of  the  pelvic  organs,  on  the  successful 
management  of  which  the  hope  of  curing  the  dysmenorrhoea  will  rest. 

The  Congestive  Dysmenorrhoea  may  be  either  primary,  that  is,  dating 
from  the  commencement  of  menstrual  life,  or  secondary,  that  is,  ac- 
quired at  a  later  period.  The  primary  cases  do  not  differ  essentially 
in  their  symptoms  from  the  neuralgic  cases ;  and  until  examination  by 
touch  is  made  they  can  only  be  conjecturally  distinguished.  In  addi- 
tion, perhaps,  to  the  subjective  signs  marking  the  neuralgic  kind,  there 
is  a  greater  sense  of  weight  and  bearing  down  in  the  pelvis,  pain 
referred  to  one  or  other  ovarian  region,  principally  the  left.  It  is 
difficult  to  derive  any  precise  information  from  external  palpation, 
because  in  congestive  as  well  as  in  neuralgic  cases,  the  hypersesthesia 
is  often  so  great  that  the  patient  shrinks  from  that  amount  of  pres- 
sure which  is  necessary  to  fairly  depress  the  abdominal  wall.  Va- 
ginal touch,  too,  is  often  difficult  for  the  same  reason,  and  it  may 
become  desirable  to  conduct  it  under  chloroform.  We  then  ascertain 
that  the  uterus  is  somewhat  enlarged,  and  on  returning  consciousness 
the  patient  complains  of  pain  on  pressure.  There  is  also  a  peculiar 
sense  of  tension  and  heat.  Of  course,  in  the  case  of  simple  congestion 
we  assume  a  normal  uterus  as  to  structure,  form,  and  position.  But 
this  coincidence,  I  believe,  is  rare.  A  normal  uterus  will  generally 
perform  its  function  normally.  The  physiological  bloodfulness,  which 
is  an  essential  condition  of  every  menstruation,  is  different  from  con- 
gestion, which  is  a  morbid  process.  The  physiological  state  is  relieved 
by  excretion.  The  morbid  state  is  only  partially  so  relieved  ;  some  of 
the  blood-elements  remain,  keeping  up  more  or  less  tension  of  the 
bloodvessels,  and  the  serum  is  effused  into  the  tissues.  Hence  con- 
gestion is  liable  to  induce  some  degree  of  permanent  enlargement, 
which  may  even  lead  to  hypertrophy  or  increased  growth  of  the  organ. 
This  enlargement  is  perceptible  to  the  touch  in  the  intermenstrual  in- 
tervals. It  induces  relaxation  of  the  pelvic  tissues  which  support  the 
uterus  ;  hence,  from  increased  weight  and  lessened  support,  the  uterus 
tends  to  sink  lower  in  the  pelvis. 

What  is  the  cause  of  this  congestion  ?  We  can  hardly  conceive  the 
idea  of  primary  congestion.  This  condition  is  almost  necessarily  the 
consequence  of  some  morbid  process  or  injury.  These  are  manifold, 
and  will  be  discussed  under  their  appropriate  heads.  But  in  especial 
reference  to  the  present  subject,  it  must  be  remembered,  that  an  organ 
which  performs  its  function  with  difficulty,  is  by  that  circumstance 
disposed  to  congestion.  Thus  the  simple  neuralgic  dysmenorrhoea  is 
pretty  sure  to  merge  sooner  or  later  into  the  congestive  form.  We 
may  go  further,  and  affirm  that  the  congestive  dysmenorrhoea,  if  not 
primarily  due  to  a  mechanical  impediment,  is  certain  to  produce  a 
mechanical  impediment,  chiefly  marked  at  the  menstrual  e]^ochs,  and 
by  the  obstruction  this  opposes  to  excretion  from  the  womb,  increas- 
ing the  pain.  The  tumefaction  of  the  mucous  membrane,  which 
commonly  exceeds  the  normal  bounds,  fills  up  and  chokes  the  cervical 
canal,  especially  at  the  os  internum.  Here  there  is  a  mechanical  ob- 
struction to  excretion.     If  the  disease  continues,  the  body  of  the  uterus, 


CONGESTIVE.  199 

increased  in  size,  and  all  the  surrounding  structures,  upon  whose 
healthy  tonicity  the  uterus  depends  for  maintenance  of  its  form  and 
position,  being  relaxed,  is  liable  to  fall  back  in  retroflexion.  This 
necessarily  increases  the  obstruction  at  the  angle  of  flexion,  that  is, 
near  the  os  uteri  internum.  Although  I  believe  this  is  the  history  of 
some  cases  of  retroflexion,  I  am  very  sure  that  in  the  majority  the 
retroflexion  is  the  primary  condition.  We  are  thus  by  several  routes 
led  to  the  discovery,  that  mechanical  obstructions  to  excretion  are  the 
most  important  factors  in  dysmenorrhoea. 

Obstructions,  it  is  almost  superfluous  to  say,  vary  in  seat,  extent, 
and  kind.  They  are  most  frequent  at  one  of  the  natural  orifices  of 
the  genital  canal.  Thus,  narrowing  of  the  os  uteri  internum,  as 
brought  about  by  flexion  or  angulation,  is  not  uncommon ;  narrowing 
of  the  OS  externum  is  very  common.  But  like  results  may  attend 
narrowing  at  any  other  part  of  the  canal,  as  in  the  vagina.  If  the 
closure  be  complete,  and  menstruation  take  place,  of  course  there  wall 
be  retention.  If  the  closure  be  incomplete  there  Avill  be  partial  reten- 
tion, the  expression  of  which  is  dysmenorrhoea.  This  partial  retention 
and  dysmenorrhoea  w^e  know  is  extremely  common.  Its  phenomena 
should,  I  think,  be  studied  in  connection  witli  those  of  complete  re- 
tention. We  shall  find  in  this  study  endless  illustrations  of  the  prop- 
osition that  one  essential  condition  of  dysmenorrhoea  is  retention  of 
menstrual  seeretion.  There  is  another  condition  to  which  retention  of 
secreted  matter  is  not  necessary.  In  many  cases  where  there  is  con- 
gestion of  the  uterus  combined  with  extreme  nervous  susceptibility, 
the  jtain  is  most  marked  at  the  outset  of  the  period,  that  is,  in  all 
probability,  before  any  pouring  forth  of  blood  into  the  uterine  cavity 
has  taken  place.  The  pain  is  explained  by  the  sudden  distension  of 
the  morbid  uterine  tissue  by  the  gathering  of  the  blood  in  the  vessels  pre- 
liminary to  secretion,  and  the  swelling  of  the  mucous  membrane.  In 
both  there  is  retention,  the  difference  being  that,  in  the  one  case  the 
menstrual  blood  is  retained  in  the  cavity  of  the  uterus  after  secretion, 
and  that  in  the  other  case,  the  blood  is  retained  in  the  tissues  of  the 
uterus.  The  point  which  brings  both  cases  together  is  that  there  is 
difficult  excretion,  causing  distension  of  the  uterine  fibre,  and  nervous 
irritation. 

The  residua]  cases,  which  do  not  fall  under  one  or  the  other  descrip- 
tion of  retention,  are  rare  indeed. 

I  have  seen  many  cases  in  which  long-standing  dysmenorrhoea  was 
cured  by  incision  of  the  os  externum,  relapse  occurring  when  the  os 
contracted  again ;  and  a  permanent  cure  was  obtained  when  the  os  was 
kept  patent. 

In  cases  of  anteversion  and  anteflexion,  without  stenosis,  dysmenor- 
rhoea has  been  from  time  to  time  relieved  or  averted  by  the  passage  of 
a  sound  a  day  or  two  before  the  onset  of  menstruation.  By  this 
means  and  rest  the  uterus  was  redressed  for  the  occasion,  and  the  ob- 
struction and  retention  were  averted.  If  this  measure  was  at  any 
time  omitted,  the  dysmenoi-rhoea  was  sure  to  come,  and  the  body  of  the 
uterus  became  very  sensibly  enlarged.  Permanent  cure  has  constantly 
followed  permanent  restoration  of  the  uterus  to  its  proper  position. 


200  D  Y  S  M  E  N  O  R  R  H  CE  A. 

Another  cause  of  dysraenorrlioea,  and  often  of  menorrhagia,  is  the 
fixing  of  the  uterus  by  perimetric  deposits,  coming  on  after  labor  or 
abortion,  or  other  conditions.  The  fixing  of  the  uterus,  although 
commonly  attended  by  patency  of  the  cervix,  seems  to  me  to  cause 
dysmenorrhoea  by  preventing  the  uterus  from  contracting,  and  also  by 
favoring  engorgement  of  its  tissues. 

Dysmenorrhoea  is  a  not  uncommon  attendant  upon  fibroid  tumors, 
which  either  produce  obstruction  by  twisting  or  compressing  the  cer- 
vical canal,  or  by  keeping  up  a  state  of  congestion,  or  by  interfering 
with  the  effective  regular  contraction  of  the  uterus.  Dysmenorrhcea 
from  the  first  cause  is  frequently  relieved  by  dilating  the  cervical  canal 
either  by  tents  or  incisions. 

Many  other  illustrations  will  occur  of  pain  analogous  to  that  of  dys- 
menorrhoea, produced  by  the  retention  in  the  uterus  of  blood-clots,  as 
after  labor  and  abortion,  of  intra-uterine  polypi,  of  the  exfoliated 
mucous  membrane  in  the  dysmenorrhoea  membranacea,  or,  in  fact,  of 
anything  which  distends  and  irritates  the  uterine  cavity.  The  differ- 
ence in  the  symptoms,  and  the  degree  of  severity,  depend  not  so  much 
on  the  nature  of  the  substance  retained,  as  upon  the  completeness  of 
the  retention  and  the  nervous  susceptibility  of  the  patient. 

A  further  proof  that  dysmenorrhoea  is  due  to  retention  lies  in  the 
changes  the  menstrual  fluid  undergoes,  and  the  character  it  presents 
when  discharged.  In  some  cases,  especially  those  in  which  there  is 
such  excess  of  blood  as  to  deserve  the  designation  of  menorrhagia,  the 
escape  being  impeded,  and  the  mucous  secretions  of  the  cavity  of  the 
uterus  being  insufficient  in  proportion  to  preserve  the  normal  state, 
clots  form.  In  other  cases,  in  which  there  may  be  no  excess  of  quan- 
tity, the  retention  is  so  protracted,  or  the  quantity  of  catarrhal  mucus 
mixed  with  it  so  large,  that  the  fluid  when  discharged  closely  resem- 
bles, in  its  syrupy  consistence  and  dark  color,  that  which  is  pent  up  by 
an  imperforate  hymen.  This  is  markedly  so  in  some  cases  of  tempo- 
rary retention  from  compression  of  the '  cervical  canal  by  a  fibroid 
tumor.  But  it  is  not  uncommon  in  obstruction  from  retroflexion,  and 
from  stenosis  of  the  os  externum.  The  discharge  is  also  often  offen- 
sive to  the  smell. 

I  have  given  a  series  of  illustrative  cases  in  support  of  the  proposi- 
tion that  dysmenorrhoea,  in  most  instances,  is  the  exponent  of  obstructed 
excretion,  in  a  memoir  in  the  "Obstetrical  Transactions"  for  1872. 

AVith  all  this  variety  of  illustration  concentrated  into  one  focus,  we 
shall  be  justified  in  repeating  the  proposition  with  which  we  started, 
namely  :  The  essential  cause  of  dysmenorrhoea — at  least,  in  the  great 
majority  of  cases — is  retention  of  the  menstrual  secretion.  The  ex- 
ceptions in  my  experience  are  very  few.  And  yet  among  these  few  ex- 
ceptions there  are  some  which  I  should  hesitate  to  consign  to  the  neural- 
gic asylum.  We  meet  with  cases,  every  now  and  then,  in  which  the 
dysmenorrhoeal  symptoms  are  very  severe,  although  there  is  no  obvious 
stenosis.  In  some  of  these  I  have  found  the  uterus  small,  perhaps  in- 
clined to  one  side,  set  in  a  short,  non-distensible  vagina.  Sometimes 
the  OS  externum  is  preternaturally  small ;  but  even  after  freely  dilating 
this,  the  dysmenorrhoea  persists.     The  subjects  of  this  kind  of  impcr- 


BY    OBSTEUCTION.  201 

feet  development — for  such  it  is — are  commonly  of  a  highly  nervous 
temperament,  acutely  sensitive  of  pain,  and  it  would  be  easy  to  say  they 
suffer  from  "  irritable  uterus/'  or  neuralgic  dysmenorrhoea.  But  this 
refuge  seems  unsatisfactory.  In  some  of  tlie  subjects  it  is  certain  that 
the  hypersesthetic  condition  has  been  gradually  develoj)ed,  caused  by 
the  frequent  pain  and  imperfectly  performed  function,  and  was  not  a 
primary  condition.  In  some  cases  I  have  seen  great  improvement,  even 
cure,  from  the  use  of  Simpson's  intra-uterine  galvanic  pessary. 

Dysmenorrhoea  from  Obstructed  Excretion. 

We  may  then  conclude  that,  in  a  very  large  proportion  of  cases  of 
dysmenorrhoea,  some  distinct  mechanical  anomaly  of  the  uterus  will  be 
found.  Careful  study  of  the  history  of  these  cases,  supplemented  by 
observation  of  the  results  of  treatment,  will  leave  little  doubt  that  these 
mechanical  anomalies  act  as  real  obstructions  to  the  menstrual  function, 
and  that  they  are  therefore  the  primary  factors  of  the  disorder,  to  the 
removal  of  which  treatment  should  be  directed. 

The  principal  mechanical  anomalies  associated  with  dysmenorrhoea 
are :  Narrowing  of  the  os  uteri  externum,  with  or  without  projecting 
conical  vaginal-portion ;  retroflexion  or  retroversion  of  the  uterus ; 
anteflexion,  or  anteversion  of  the  uterus ;  lateriversion ;  torsion  of  the 
uterus  (see  Fig.  23,  p.  47);  inflammatory  and  hypersemic  states  of 
the  uterus;  fibroid  tumors  in  the  walls  of  the  body,  and  especially  in 
the  neck  of  the  uterus ;  polypi  in  the  uterus ;  tumors  or  effusions  out- 
side the  uterus,  pressing  upon  it,  such  as  pelvic  peritonitis,  or  perime- 
tritis, and  retro-uterine  hsematocele,  which  impede  its  mobility,  and 
keep  up  hypersemia  in  it.  These  conditions  may  exist  simply,  or  two 
or  more  may  be  combined.  I  propose  now  to  discuss,  in  relation  to 
dysmenorrhoea,  the  narro^v  os,  and  the  displacements  of  the  uterus. 
The  other  conditions  will  be  studied  under  their  appropriate  heads. 

This  doctrine  has  not,  it  is  true,  met  with  general  acceptance  amongst 
those  who  have  not  applied  to  the  study  of  the  diseases  of  the  ovaries 
and  uterus  the  same  method  which  they  might  think  necessary  in  the 
case  of  other  organs.  So  long  as  they  regard  the  ovaries  and  uterus 
from  this  exceptional  point  of  view,  so  long  must  they  be  under  the 
dominion  of  arbitrary  hypotheses.  If  a  patient  suffers  from  dyspnoea, 
the  first  thought  is  to  explore  the  organs  of  respiration.  And  in  the 
great  majority  of  cases  a  physical  condition  of  these  organs  adequate 
to  explain  the  distress  in  breathing  is  discovered.  So  in  like  manner, 
whenever  any  organ  performs  its  function  with  difficulty,  it  is  inferred 
that  the  organ  is  out  of  gear.  But  with  a  strange  inconsistency  they 
exclude  the  uterine  and  ovarian  functions  from  this  process  of  inquiry. 

I  have  sketched  the  most  common  forms  of  conical  vaginal-portion 
and  stenosis  of  theos  externum  in  the  following  figures. 

They  are  mostly  congenital,  and  may  be  traced  back  to  imperfect 
development.  The  vaginal-portion  may  project  into  the  vagina  half  an 
inch,  an  inch,  or  even  as  much  as  two  inches.  Sometimes  the  vaginal- 
portion  is  rounded,  representing  the  half  of  a  globe.  In  some  cases 
the  excessive  projection  is  due  to  acquired  hypertrophic  elongation  of 


202 


DYSMEIfOEEHCEA. 


the  infra-vaginal-portion.  In  the  ordinary  construction  the  cervical 
canal  communicates  freely  with  the  vagina  by  an  open  transverse 
fissure ;  inclining,  indeed,  to  the  circular  form  in  the  virgin.    The  form 


Fig.  54. 


Showing  one  form  of  the  conical 
vaginal-portion. 


Showing  another  form  of  the  conical 
vaginal-portion. 


of  the  cervical  cavity  is  thus  a  flattened  cone  or  funnel,  of  which  the 
base  is  open  (see  Figs.  10,  12).  The  vaginal-portion  projects  as  a 
flattened  hemisphere  scarcely  half  an  inch  into  the  vagina,  the  vagina 


Fig.  56. 


Showing  a  third  form  of  the  conical  vaginal- 
portion. 


Showing  a  common  form  of  narrow 
OS  uteri,  attended  by  dysmenorrhoea 
and  sterility. 


being  reflected  oflP  from  the  cervix  a  little  above  the  level  of  the  os 
externum. 

Instead  of  the  natural  free  communication  between  the  cervical 
cavity  and  the  vagina,  the  os  externum  is  so  contracted  as  to  form  a 
sensible  obstruction.  Indeed,  sometimes  the  ordinary  uterine  sound 
can  be  passed  only  with  difficulty ;  and  I  have  known  the  occlusion  to 
be  complete,  requiring  some  little  force  to  break  down  a  thin  membran- 
ous septum  formed  at  the  orifice.  As  soon  as  the  os  uteri  externum  is 
penetrated  by  the  sound,  it  is  usually  found  that  the  point  enters  into 
a  sufficiently  capacious  cervical  cavity.  This  cavity  is,  in  fact,  exactly 
spindle-shaped ;  it  narrows  again  towards  the  os  uteri  internum.  In 
cases  of  protracted  suflFering  from  dysmenorrhoea  attending  this  ijeculiar 
form  of  cervix,  I  have,  however,  generally  found  that  the  sound  passes 
through  the  os  internum  without  difficulty.  It  is  by  this  observation  that 
I  have  come  to  the  conclusion  that  in  some  cases  the  excessive  projec- 


BY    OBSTEUCTIOISr. 


203 


Fig.  58. 


Section  showing  conical  cervix  with  small 
OS  externum. 


tion  of  the  vaginal-portion  is  simply  due  to  the  vagina  being  reflected 
off  at  a  higher  level  than  usual.     The 
sound  shows  the  entire  length  of  the 
uterus  to  be  normal. 

The  seat  of  the  obstruction,  then,  I 
believe  to  be  most  commonly  at  the  os 
externum.  The  obstruction  is  due 
chiefly  to  the  small  round  os  itself; 
partly  to  the  pointed  elongated  form  of 
the  lower  part  of  the  vaginal-portion ; 
and  partly  to  an  unusual  rigidity  of 
structure  of  this  part,  which  impedes 
the  expanding  action  natural  to  the 
healthily  formed  os  uteri. 

When  obstruction  is  experienced  at 
the  OS  internum,  I  have  almost  always 
found  it  to  be  due  to  the  flattening  of 
the  canal  at  this  point,  caused  by  ex- 
treme flexion  or  angulation  of  the  body 
of  the  uterus  upon  the  neck.  The  sound 
will  generally  pass,  by  giving  it  a  mode- 
rate curve,  by  tilting  up  the  down-bent 
body  with  a  guiding  finger,  and  carry- 
ing the  handle  of  the  sound  well  backwards  in  the  case  of  anteflexion, 
and  vice  versa. 

Dysmenorrhoea  from  obstruction  at  the  os  uteri  internum,  or  at  some 
point  below  it,  is  closely  allied  in  pathology  and  symptoms  with  occlu- 
sion of  the  uterus  and  complete  retention  of  the  menstrual  fluid.  It 
is,  in  fact,  a  minor  or  incomplete  degree  of  occlusion. 

The  consequences  of  the  described  obstructions  take  place  in  retro- 
grade or  ascending  order  above  the  seat  of  obstruction.  They  are:  1. 
Congestion  and  enlargement  of  the  body  of  the  uterus,  disposing  to 
menorrhagia  at  first,  and  causing  uterine  spasm  and  colic  ;  2.  A  similar 
condition  of  the  Fallopian  tubes,  and  tendency  to  undue  patency  of  the 
uterine  mouths  of  the  tubes  (see  Figs.  20,  21,  22,  23) ;  3.  Congestion, 
enlargement,  inflammation  of  the  ovaries,  determining  (a)  intra-alar 
hemorrhage,  (b)  retro-uterine  hsematocele,  (c)  limited  pelvic  peritonitis, 
with  or  without  adhesions  of  tubes  and  ovaries  to  surrounding  struc- 
tures ;  4.  As  an  ulterior  result,  continued  obstruction  may  entail, 
through  the  action  of  inflammation  or  long  interference  with  function, 
atrophy  of  the  ovaries,  and  extinction  of  the  menstrual  phenomena. 

All  the  above  consequences  may  occur  in  single  women. 

When  the  subjects  of  uterine  obstruction  enter  upon  married  life, 
other  consequences  are  added.  These  are :  Increased  congestion  and 
inflammation  of  the  body  of  the  uterus ;  increased  liability  to  ovarian 
irritation ;  increased  tendency  to  menorrhagia ;  acute  and  chronic 
cervicitis  with  leucorrhoea ;  vaginitis  ;  vaginismus ;  dyspareunia  ;  ster- 
ility ;  or,  in  the  rare  event  of  impregnation,  abortion,  or  dystocia.  I 
have  learned  that  a  history  of  abortion  is  generally  to  be  mistrusted. 
A  presumed  abortion  is  likely  to  have  been  nothing  more  than  menor- 


204  DYSMENOERHCEA, 

rhagia.  The  barren  woman  would  fain  console  herself  with  the  delu- 
sion of  a  blighted  hope.  Of  course  it  is  not  intended  to  convey  the 
idea  that  these  consequences  are,  one  and  all,  constant.  But  I  believe 
it  is  rare  for  the  subject  of  narrow  os  externum  uteri,  alone  or  com- 
bined, as  it  frequently  is  with  retroflexion  of  the  uterus,  to  escape  from 
some  of  them.  Dysmeuorrhoea,  dyspareunia,  and  sterility  will  com- 
monly follow ;  and,  continued  through  the  period  of  ovarian  activity, 
will  render  life  miserable,  even  if  health  be  not  utterly  broken  doM'n. 

The  symptoms  of  dysmeuorrhoea  from  obstructed  excretion  ex])ress 
the  several  pathological  conditions  which  are  called  into  action.  Pain 
is  the  most  urgent  symptom.  This  usually  comes  on  as  a  heavy  aching 
sensation,  even  before  the  flow  appears.  The  seat  is  pelvic,  spreads  to 
the  sacrum,  loins,  one  or  both  iliac  regions,  and  often  extends  down  the 
thighs.  As  the  flow  appears  there  is  sometimes  relief  from  pain,  but 
more  commonly  it  assumes  an  expulsive  bearing-down  character.  It 
rises  sometimes  to  such  intensity  that  the  patient  is  obliged  to  take  to 
bed.  The  constitutional  reactions  of  this  pain  are  often  great.  Pros- 
tration approaching  to  collapse  may  ensue,  violent  headaches,  syncope, 
retching,  vomiting  are  not  unfrequent.  I  have  witnessed  marked 
stupor  and  hebetude,  loss  of  memory,  loss  of  energy,  want  of  all  power 
of  fixing  attention,  delirium,  even  mania.  These  symptoms  subside, 
or  are  mitigated  as  the  flow  ceases,  but  occasionally  last  for  several 
days,  leaving  the  patient  so  exhausted  and  depressed  in  body  and  mind 
that  she  has  scarcely  time  to  rally  before  the  next  period  returns,  when 
all  her  distress  is  renewed.  That  these  symptoms  depend  chiefly  upon 
the  hypersemic  state  of  the  uterus  seems  proved  by  the  observation  re- 
peatedly made,  that  touching  the  cervix  or  fundus  with  the  finger  will 
produce  the  same  phenomena,  and  that  the  uterus  is  really  enlarged 
and  painful.  Enlargements  of  the  abdomen  from  perverted  nervous 
action,  resembling  those  which  occur  at  the  climacteric  period,  are  fre- 
quent at  the  menstrual  periods.  The  breasts  also  frequently  enlarge  at 
these  times,  and  become  painful,  in  response  to  the  ovario-uterine  dis- 
tress. The  effect  upon  the  menstrual  function  varies.  In  one  class  of 
cases  menorrhagia  is  induced,  the  result,  no  doubt,  of  the  extreme 
hypersemia  caused  by  the  obstruction.  In  these  cases  the  intermenstrual 
interval  is  often  reduced  to  three  weeks  or  less,  whilst  the  flow  nei'sists 
for  a  week  or  longer.  Clots  are  frequently  passed,  indicating  retention 
in  the  cavity  of  the  uterus.  The  case  then  resembles  abortion,  and  not 
seldom,  patients  believe  they  have  aborted.  This,  as  I  have  said,  is 
rarely  the  case.  There  has  been  no  conception.  The  menorrhagia  is 
commonly  followed  by  leucorrhoea,  another  means  which  Nature  adopts 
to  lessen  the  hypersemia.  More  or  less  pain  often  persists  throughout  the 
interval,  and  is  liable  to  exacerbation  on  any  exertion  or  emotion.  This 
is  due  to  the  continuance  of  hyperremia,  and  even  to  some  hypertro])hv 
of  the  uterus.  When  dysmeuorrhoea  depends  upon  obstruction  of  the 
OS  externum  or  retroflexion  or  anteflexion,  it  commonly  begins  with  the 
first  advent  of  the  ovarian  function,  and  continues  in  spite  of  all  ordi- 
nary treatment.  I  have  notes  of  a  case  which  shows  in  a  striking- 
manner  the  severity  of  the  symptoms  sometimes  produced.  A  young 
lady  had  been  married  two  years  without  pregnancy.     Since  marriage 


SYMPTOMS.  205 

she  had  suffered  from  metrorrhagia,  and  several  attacks  considered  to 
be,  and  treated  as  peritonitis.  During  the  last  six  months  she  had  a 
constant  sense  of  swelling,  ^vith  pain  in  the  left  ovarian  region;  vomit- 
ing attended  the  pain.  This  had  been  relieved  by  leeching.  When  I 
saw  her,  metrorrhagia  had  lasted  six  weeks  without  cessation.  Great 
prostration  was  present,  with  irritative  fever,  reminding  me  of  pysemic 
puerperal  fever.  I  found  a  small  conical  cervix,  with  an  os  so  minute 
that  it  required  considerable  pressure  to  introduce  the  uterine  sound ; 
the  cervix  was  deviated  to  the  left ;  there  was  defined  tumefaction  and 
pain  in  the  left  ovarian  region.  I  inferred  tliat  the  narrowed  os  ex- 
ternum, impeding  the  flow  of  blood  from  the  uterus,  led  to  the  forma- 
tion of  coagula  in  the  cavity ;  that  these  coagula  were  broken  up  by 
decomposition  ;  that  absorption  of  septic  matter  took  place,  causing 
constitutional  symptoms,  and  possibly  peritonitis  or  cellulitis  in  the  left 
broad  ligament ;  that  the  tumefaction  in  the  left  broad  ligament  might 
also  be  due  to  hemorrhagic  effusion,  or  to  congestion  of  the  ovary.  I 
split  the  cervix  with  my  scissors.  The  metrorrhagia,  which  had  per- 
sisted for  six  weeks,  and  was  abundant  at  the  moment  of  the  operation, 
ceased  in  a  few  clays,  the  pain  abated,  and  recovery  ensued. 

The  escape  of  a  muco-sanguineous  offensive  discharge,  when  the  os 
externum  is  opened  by  incision,  is  a  very  common  occurrence.  This 
indicates  that  chronic  endometritis  or  uterine  catarrh  is  one  of  the  con- 
sequences of  this  malformation. 

In  another  class  of  cases,  arising  either  primarily  or  secondarily  upon 
menorrhagia,  the  menstrual  flow  gradually  decreases,  and  it  may  even 
end  in  amenorrhoea.  In  these  cases  it  may  be  conjectured  that  the 
ovaries  undergo  some  change  of  an  atrophic  character,  the  result  or  not 
of  inflammatory  processes  in  the  organs  themselves,  or  in  the  surrounding 
tissues. 

The  association  of  painful  menstruation,  uterine  hemorrhage,  and  ster- 
ility, with  a  peculiar  formation  of  the  os  uteri,  has  long  been  recognized. 
Indeed,  this  fact  in  pathology  appears  to  be  simply  a  recovered  legacy 
from  the  most  remote  epoch  of  medical  history.  There  is  a  passage  in 
Aetius,  in  which  not  only  is  the  dependence  of  sterility  upon  a  con- 
tracted OS  uteri  pointed  out,  but  the  supposed  modern  treatment  of  di- 
lating it  by  compressed  sponge-tents  is  also  described.  The  late  Dr. 
Macintosh  was  mainly  instrumental  in  reviving  and  applying  this 
knowledge  to  practice.  Professor  Simpson  in  Edinburgh,  Dr.  Oldham, 
myself,  and  others,  in  London,  accepted  the  doctrine.  On  the  Conti- 
nent it  has  met  with  less  favor.  But  in  America  it  is  almost  univer- 
sally recognized. 

If  we  reflect  upon  the  normal  uterus,  the  characteristics  of  which 
are:  a  nearly  straight  axis  from  the  fundus  to  the  os  externum,  slight 
anteversion  only,  an  os  uteri  externum  consisting  of  a  free  transverse 
slit,  a  cervical  canal  admitting  the  ready  passage  of  the  sound  nearly 
or  quite  straight,  we  cannot  avoid  the  conclusion  that  these  are  condi- 
tions fit  for  the  easy  performance  of  menstruation.  It  might,  a  'priori, 
be  predicated  that  where  these  conditions  do  not  exist,  difficult  menstru- 
ation must  result.  Clinical  observation  amply  proves  that  this  is  so. 
But  opinions  differ  as  to  the  exact  nature  and  seat  of  the  obstruction. 


206  DYSMENORRHCEA. 

Simpson  thought  the  seat  of  stricture  was  often  at  the  os  internum,  and 
this  view  has  been  adopted  by  several  men  of  experience  in  London. 
The  question  is  one  of  great  importance  to  determine.  It  stands  liter- 
ally at  the  very  threshold  of  the  subject.  If  the  obstruction  be  always, 
or  even  often,  at  the  os  internum,  it  follows  that  treatment  must  be  di- 
rected to  the  dilatation  of  this  part.  Now,  dilatation  of  this  isthmus 
by  bougies  or  expanding  tents  is  attended  but  with  transitory  results. 
The  isthmus  very  soon  regains  its  ordinary  calibre.  Dilatation  by  in- 
cision is  not  only  of  transitory  result,  for  the  isthmus  quickly  contracts 
again,  but  it  is  attended  by  great  danger.  The  bloodvessels  enter  the 
cervix  just  about  this  level,  some  penetrate  deeply  into  its  structure, 
and  the  venous  canals  are  maintained  as,  more  or  less  rigid  tubes.  An 
incision  half  an  inch,  or  even  a  quarter  of  an  inch  deep  will  be  very 
liable  to  divide  some  of  these  vessels.  Hence,  as  a  first  danger,  we 
have  to  apprehend  profuse,  even  "furious"  bleeding;  next,  from  the 
gaping  of  the  divided  veins  and  the  injury  to  the  tissues  in  which  they 
run,  there  is  great  liability  to  pelvic  inflammation  and  septicaemia. 
These  are  no  theoretical  dangers.  Many  cases,  some  fatal,  are  well 
known.  To  illustrate  this  point,  I  made  many  sections  at  the  level  of 
the  OS  uteri  internum.  The  disposition  of  the  vessels  is  shown  in  Figs. 
59,  60.^  The  same  figures  show,  what  almost  every  section  at  this 
level  shows,  that  the  natural  calibre  of  the  isthmus  will  just  about  ad- 
mit the  passage  of  the  uterine  sound.  This  coarctation  has  been  demon- 
strated to  be  normal  by  Dr.  H.  Bennet  in  the  living,  by  Boullard  in 
the  dead,  and  is  no  longer  disputed.  No  operation,  then,  is  needed  to 
make  it  larger.  If  the  sound  will  pass,  we  may  be  satisfied  as  to  the 
efficiency  of  the  os  uteri  internum ;  and  in  my  experience  it  is  very  rare 
indeed  to  find  serious  difficulty  in  passing  it.  If  it  does  not  pass  readily, 
by  far  the  most  common  cause  is  excessive  flexion,  mostly  retroflexion, 
of  the  body  upon  the  cervix.  The  point  of  angulation  is  at  or  near 
the  OS  internum,  so  that  the  sound  will  not  pass  unless  the  body  be  lifted 
up  so  as  to  straighten  its  axis,  or  the  sound  be  much  curved.  When 
these  things  are  done,  the  angle  or  spur  of  flexion  is  overcome,  and  the 
calibre  of  the  isthmus  is  found  to  be  normal.  What  need,  then,  to  en- 
large it  by  incision?  Will  incision  help  to  straighten  the  uterus?  If 
the  incision  be  made  into  the  spur  of  flexion,  and  the  wound  be  kept 
from  closing,  we  may,  it  is  true,  get  a  straighter  passage  between  the 
cervix  and  body.  But  can  we  depend  upon  so  keeping  a  wider  canal  ? 
Of  this  I  think  proof  is  required.  The  rational  course  is,  where  there  is 
obstruction  from  angulation,  and  this  is  frequent,  to  attack  the  flexion. 

For  these  reasons  I  disagree  from  those  who  insist  upon  the  frequency 
of  stricture  of  the  os  internum,  and  apply  their  treatment  accordingly. 

Before  describing  the  operation  of  incision,  it  is  proper  to  describe 
and  to  discuss  the  value  of  the  methods  of  dilating  by  bougies  and 
tents.  This  was  first  done  in  modern  times  by  Macintosh,  and  has 
been  largely  followed.  Various  dilating  materials  have  been  used. 
One  was  to  fashion  a  tent  made  of  ivory  out  of  which  the  bony  matter 
was  taken  by  hydrochloric  acid.     Such  a  tent,  when  applied  inside  the 

1  On  "  Dysmenorrhcea,"  &c  ,  "  Obstetrical  Transactions,"  1866. 


SEAT    OF    STRICTURE. 


207 


cervix  uteri,  will  swell  to  about  double  its  ordinary  size,  and  so  distend 
the  canal  in  which  it  is  placed.  Metal  bougies  have  been  applied  of 
gradually  increasing  size,  as  for  stricture  of  the  male  urethra.  A  steel 
sound  provided  with  a  mechanism  for  expanding  its  calibre  after  intro- 
duction into  the  cervix  has  been  advocated  by  Dr.  Priestley  and  others. 


Fig.  60. 


Sections  of  uterus  made  at  os  internum — (ad  nat.). 
Showing  the  normal  size  of  the  os  internum,  the  circular  disposition  of  the  fibres  around  it,  and  the 

bloodvessels  in  proximity. 

Of  late  the  favorite  agents  have  been  compressed  sponge  and  laminaria-' 
tents.  The  sponge  is  made  into  a  conical  form  and  waxed  over.  Tents 
of  this  material,  when  introduced,  soften  and  swell  by  imbibition  of  the 
fluids  secreted. 

The  patient  should  be  undressed,  in  bed,  and  lie  on  her  left  side, 
knees  drawn  up.  To  introduce  the  sponge-tents,  first  of  all  pass  the 
uterine  sound  to  determine  accurately  the  dimension  and  direction  of 
the  canal ;  then  the  tent  mounted  on  a  stilet  is  introduced,  and  when 
in  situ,  it  is  well  to  plug  the  vagina  below  by  pledgets  of  lint  soaked 
in  carbolic  acid  oil.  After  a  few  hours  it  will  have  expanded  to  its  full 
extent,  and  may  be  removed.  If  it  be  found  that  the  dilatation  ob- 
tained is  insufficient,  another  tent  may  now  be  passed. 

The  laminaria-tents  are  now  usually  made  about  two  inches  long  and 
hollowed  out,  that  is,  tubular.  I  have  contrived  a  very  convenient  in- 
strument (see  Fig.  41,  p.  127)  to  carry  them  into  their  place,  which  has 
been  sold  by  the  London  instrument-makers  for  several  years.  Re- 
cently, my  friend  Dr.  Charles  Godson  has  so  modified  my  instrument, 
that  the  tube-bearing  stilet  may  be  set  at  any  convenient  angle. 

A  suitable  laminaria-tube  is  mounted  on  the  stilet,  when  it  virtually 
forms  part  of  the  equivalent  of  a  uterine  sound,  and  is  almost  as  easy 
to  introduce.  The  forefinger  of  the  left  hand,  serving  as  a  guide,  is 
applied  to  the  edge  of  the  os  uteri,  whilst  the  instrument  carrying  the 
tent  is  handled  by  the  right  hand.  The  tent  end  is  carefully  slipped 
up,  until  nearly  the  whole  length  has  passed  the  os  externum.     By 


208  DYSMElSrOREHCEA. 

this,  and  also  by  a  sense  of  resistance  overcome,  we  know  the  os  in- 
ternum has  been  passed.  Then,  keeping  the  forefinger  on  the  os,  with- 
draw the  handle  of  the  instrument,  whilst  the  catheter  is  kept  steady 
against  the  os.  The  stilet  thus  withdrawn  from  the  laminaria-tube, 
this  is  left  in  situ.  To  secure  it  here,  until  it  swells,  when  it  will  hold 
itself,  plug  lightly  with  lint  soaked  in  carbolic  acid  oil. 

The  tent  takes  about  six  or  eight  hours  to  swell  to  its  full  extent.  If 
the  constriction  be  rigid,  or  the  patient  very  susceptible,  it  is  not  un- 
common for  vomiting  and  pain  to  come  on  when  the  excentric  pressure 
stretches  the  uterine  fibre ;  it  is  therefore  desirable  to  give  a  sedative 
an  hour  or  two  after  the  application.  The  necessary  time  taken  for  the 
action  of  the  tent  suggests  a  practical  rule  in  the  selection  of  the  hours 
for  introducing  it. 

It  will  combine  the  least  distress  to  the  patient  with  the  greatest  con- 
venience to  the  surgeon,  to  introduce  the  tent  in  the  evening,  and  to 
visit  her  early  in  the  morning  to  remove  it ;  or,  it  may  be  introduced 
in  the  morning  and  removed  in  the  evening.  The  os  internum  yields 
with  most  difficulty.  Sometimes  the  tent  is  gripped  at  this  point  so 
forcibly,  that  a  deep  furrow  or  circular  constriction  is  formed,  and  the 
part  of  the  tent  over  this  point  having  expanded  freely,  considerable 
resistance  is  opposed  to  the  removal. 

What  is  the  effect  of  these  measures  ?  The  immediate  effect  is  un- 
doubtedly to  expand  the  cervical  canal.  A  laminaria-tube,  the  size 
of  a  No.  8  bougie,  will  so  expand  the  canal  that  it  will  admit  the  finger. 
The  irritation  produced  by  the  presence  of  the  tube  causes  a  free  secre- 
tion of  mucus,  which  lasts  for  a  day  or  two.  But  does  the  canal  re- 
main enlarged  ?  It  does  not ;  in  a  very  few  days  it  has  contracted  to  its 
old  diameter,  and  matters  are  in  statu  quo.  To  meet  this,  the  operation 
has  been  repeated  time  after  time,  either  until  the  patience  of  the  suf- 
ferer was  exhausted,  or  until  serious  accidents  arose. 

That  the  cervix  possesses  the  property  of  contracting  again  after 
simple  mechanical  stretching  is  amply  proved  by  its  occasional  com- 
plete return  to  its  previous  diameter  after  parturition,  during  which  a 
far  greater  force  than  that  exerted  by  tents  is  applied. 

The  accidents  attending  the  process  are  not  inconsiderable,  and  have 
been  too  much  underrated  by  those  who  prefer  dilatation  by  tents  to 
incision,  on  the  mistaken  presumption  that  incision  is  more  dangerous. 
Numerous  cases  have  occurred  of  pelvic  cellulitis  or  peritonitis,  and 
some  of  septicsemic  fever  after  the  use  of  sponge-tents ;  and  similar  acci- 
dents, although  less  frequently,  have  followed  the  use  of  laminaria-tents. 
Marion  Sims  relates  several  such  cases,  some  so  severe  as  to  threaten 
to  be  fatal.  Dr.  L.  Aitken^  relates  others,  and  one  in  which  retro- 
uterine hseraatocele  also  occurred.  He  insists  upon  the  very  proper 
caution  that  they  should  not  be  used  when  there  is  any  inflammation. 

We  may  then  conclude  that  the  use  of  tents  to  dilate  the  cervix  uteri 
is  not  efficient,  and  does  not  possess  the  advantage  of  being  safer  than 
incision.  I  entirely  agree  with  Marion  Sims  that  incision  properly 
performed  is  less  dangerous,  less  painful,  and  far  more  effective  than 

1  Edin.  Med.  Journ.,  1870. 


USE    OF    TENTS.  209 

any  mode  of  dilatation  by  plugs  or  tents ;  and  this  is  the  testimony  of 
patients  who  have  gone  through  both  operations. 

The  operation  of  Dilatation  by  Incision. — To  combine  the  conditions 
of  least  danger,  least  pain,  and  greatest  success  is  the  object  to  aim  at. 

I  have  already  pointed  out  the  objections  to  dividing  the  os  uteri 
internum.  By  eliminating  this  proceeding  we  greatly  lessen  the 
danger,  and  do  not,  I  believe,  diminish  the  benefit  of  the  operation. 
Further  to  lessen  the  danger  we  must  eschew  a  class  of  instruments 
which  must  be  regarded  rather  as  machines  than  as  surgical  instruments. 
I  am  very  unwilling  to  underrate  the  ingenuity  which  has  been  dis- 
played in  the  contrivance  of  the  various  two-bladed  metrotomes.  It 
is,  however,  against  these  that  my  objection  is  urged,  and  especially 
against  the  most  ingenious  in  its  mechanism  of  all,  that  of  Dr.  Green- 
halgh.  This  is  adapted  to  divide  the  os  internum,  and  therefore  is 
already  excluded  by  the  reasons  advanced  against  this  proceeding.  It 
moreover  exceeds  the  rest  of  the  two-bladed  metrotomes  in  its  automatic 
character.  The  two  blades,  as  in  all  the  contrivances  of  their  class,  are 
concealed  in  a  narrow  sheath  open  at  both  sides,  so  that  they  can  be 
introduced  into  or  through  the  cervix  before  being  allowed  to  cut. 
When  introduced  thus  guarded  to  the  desired  extent,  by  a  mechanism 
in  the  handle,  the  blades  spring  out,  one  on  either  side,  and  make  their 
incisions  whilst  the  instrument  is  being  withdrawn.  With  some  in- 
struments the  extent  of  divergence  of  the  blades,  and  therefore  the  depth 
and  place  of  the  incisions,  is  regulated  by  the  pressure  of  the  operator's 
hand.  In  this  respect  the  instruments  are  good.  It  is,  however,  dif- 
ficult to  insure  perfect  accuracy  in  this  way,  and  there  is  really  no  ad- 
vantage in  cutting  both  sides  simultaneously.  But  Dr.  Greenhalgh's 
instrument  does  not  possess  the  advantage  of  being  controlled  in  its 
work  by  the  operator.  The  blades  are  set  beforehand,  so  as  to  diverge 
to  a  given  extent.  The  sheathed  blades  are  then  passed  through  the 
cervix,  when  the  mechanism  by  which  they  are  opened  is  set  at  work, 
and  from  this  moment  the  operation  is  performed  by  automatic  ma- 
chinery. The  blades  cut  as  they  are  set,  beyond  observation  of  sight  or 
touch ;  the  incisions  they  make  cannot  be  regulated  according  to  indi- 
cations obtained  during  the  operation.  Now,  the  thickness  of  the  cer- 
vix uteri  at  the  place  of  incision,  and  the  nearness  to  which  the  vessels 
may  approach  the  inner  surface,  are  not  absolute  invariable  quanti- 
ties. Setting  the  blades  to  diverge  one-eighth  of  an  inch  only  beyond 
the  limit  of  safety — a  limit  which  it  must  be  borne  in  mind  we  are 
unable  to  determine — will  involve  the  dangers  of  hemorrhage  and  septi- 
caemia. 

Two  other  serious  objections  tell  against  the  double  metrotomes.  I 
have  frequently  observed,  in  cases  requiring  incision,  that  there  is  ob- 
liquity of  the  uterus.  The  axis  of  the  uterus  is  often  inclined  to  the 
right  or  to  the  left.  A  two-bladed  instrument  will  not  respect  this  ob- 
liquity, but  will  be  in  danger  of  cutting  the  two  sides  of  the  cervix  un- 
equally. The  side  nearest  the  median  line  will  be  cut  imcompletely, 
because  it  stands  at  a  higher  level,  whilst  the  other  side,  being  on  a 
lower  level,  will  be  caught  in  the  sweep  of  the  knife  at  a  higher  point, 
where  the  vessels  enter  the  uterine  neck  (see  Fig.  61). 

14 


210 


DYSMENOERHCEA. 


Fig.  61. 


The  otlier  objection  has  been  pointed  out  to  me  by  Dr.  Aveling  him- 
self, the  inventor  of  the  best  double  metrotome.  Examining  the  action 
of  the  metrotome  on  a  number  of  uteri  taken  out  of  the  body,  he  ob- 
served that  the  thickness  of  the  two  sides  of  the  cervix  often  varied 
considerably,  so  that  the  two  blades,  although  diverging  at  an  equal 
angle,  would  cut  to  a  dangerous  extent  on  one  side.  For  this  reason 
he  has  abandoned  two-bladed  instruments. 

The  governing  idea,  then,  of  this  mechanism  rests  on  the  assumption 
that  the  conditions  of  the  part  to  be  cut  are  constant  as  to  disposition 
of  vessels,  thickness,  and  relations.  But  no  such  constancy  exists  in 
nature.  Cases  vary  infinitely.  The  surgeon,  then,  here,  as  in  every 
other  operation  upon  the  body,  must  be  able  to  adapt  every  step  of  his 
proceedings  to  the  peculiarities  of  the  case  in  hand.  He  must  use 
tools  that  will  do  his  bidding  with  nicety  from  first  to  last. 

The  objections  stated  apply,  although  with 
less  force,  to  all  two-bladed  metrotomes,  even 
when  designed  to  cut  the  lower  or  vaginal- 
portion  of  the  cervix  only.  The  degree  to 
which  this  portion  projects  into  the  vagina 
varies  greatly.  Thus,  in  some  cases  the  vagi- 
nal-portion forms  a  conical  mass,  projecting 
an  inch  and  a  half  into  the  vagina,  whilst  in 
others  there  is  hardly  any  projection,  the  os 
uteri  being  almost  flush  with  the  vaginal  roof. 
It  is  difficult  to  work  two  blades  simultane- 
ously with  the  required  precision  in  all  cases. 
It  is  generally  quite  safe  to  divide  all  that 
part  which  projects  into  the  vagina.  But 
where  the  cervix  is  entirely  supra-vaginal,  a 
degree  of  nicety  is  required  which  it  must  be 
difficult  to  secure  with  two  blades  working  at 
once. 

I  do  not  condemn  these  instruments  with- 
out having  tried  them.  I  had  used  them 
fairly  before  the  objections  expressed  were  re- 
vealed to  me. 

The  operation  sometimes  is  attended  or 
followed  with  an  amount  of  nervous  disturbance  out  of  all  proportion 
to  its  severity.  This  is  greatly  emotional,  and  depends  upon  the  de- 
gree of  apprehension  excited  in  the  mind  of  the  patient,  of  her  sus- 
ceptibility, and  of  the  degree  of  mental  tension  sustained  before  and 
during  the  operation.  The  consequence  is  generally  restlessness, 
sometimes  hysteria.  Pain  after  the  operation  is  not  commonly  com- 
plained of.  In  the  event  of  sleeplessness,  nervous  disturbance,  or 
pain,  it  is  proper  to  provide  a  sedative  to  be  taken  at  night. 

The  after-treatment  is  simple.  To  avert  the  risks  of  hemorrhage 
and  inflammation,  the  patient  should  keep  her  bed  for  four  days,  and 
not  be  allowed  to  leave  her  room  under  a  week.  If  there  be  any 
bleeding  to  cause  uneasiness,  the  vagina  may  be  plugged  with  strips  of 
lint  soaked  in  oil.     The  ordinary  diet  may  be  given.     The  sound  may 


Eepresenting  the  aclion  of 
the  two-bladed  Metrotomes  in 
cutting  the  os  internum.  (Half- 
size). 

A,  B  B,  c,  the  dotted  lines  di- 
verging from  A  to  their  extreme 
distance  at  b  b,  and  converging 
again  at  c.  At  b  b  the  os  inter- 
num is  divided,  perhaps  to  an 
unequal  depth,  according  to  the 
thickness  of  the  uterus  at  this 
part. 


INCISION     OF    THE    CEEVIX.  211 

be  passed  on  the  fourth  day,  to  lightly  part  the  freshly-cut  lips  of  the 
Avound,  and  secure  against  reunion.  When  the  operation  has  been 
performed  as  described,  and  these  precautions  have  been  observed,  I 
have  never  seen  any  serious  symptoms  arise.  Where  symptoms  of 
peritonitis  have  occurred  it  has  generally  been  from  getting  up  too 
soon,  from  exposure  to  cold,  or  undue  excitement.  The  simple  passing 
of  the  uterine  sound  for  the  purpose  of  diagnosis,  has  been  followed 
by  pelvic  cellulitis  or  peritonitis.  It  is  not,  therefore,  possible  to  pre- 
dict absolutely  that  in  even  the  most  favorable  condition,  such  a  result 
may  not  follow  the  operation  under  discussion.  But  I  am  warranted 
by  very  considerable  personal  experience,  in  affirming  that  with  due 
care  the  risk  of  danger  from  the  operation  is  infinitely  small,  and  not 
to  be  compared  with  the  protracted  and  repeated  suffering  and  danger 
attending  the  obstruction  which  the  operation  is  designed  to  remove. 

In  the  event  of  secondary  hemorrhage  occurring,  as  it  sometimes 
will,  within  the  first  twenty- four  hours,  it  is  well  not  to  trust  to  ordi- 
nary plugging.  The  most  satisfactory  plan  is  to  introduce  the  specu- 
lum, to  bring  the  os  uteri  well  into  view,  to  wipe  away  all  blood,  to 
seize  one  lip  with  a  Sims's  tenaculum-hook,  so  as  to  open  the  os,  and 
steady  it ;  then  to  insert  into  it  a  small  strip  of  lint,  soaked  in  per- 
chloride  of  iron.  This  direct  application  of  the  styptic  is  generally 
eifectual ;  it  avoids  the  risk  of  continued  bleeding.  When  the  styptic 
plug  is  applied,  the  vagina  may  be  packed  below  by  strips  of  lint, 
soaked  in  carbolic  acid  oil. 

Immediately  after  the  operation,  or  on  the  next  day,  it  is  generally 
useful  to  insert  a  Wright's  intra-uterine  stem.  This  instrument  con- 
sists of  a  small  perforated  disk,  on  which  are  mounted  two  stems  about 
two  inches  long,  which  are  brought  together  by  means  of  a  tubular 
carrier.  When  so  united  the  stem  and  its  holder  form  virtually  a 
sound,  and  is  as  easy  of  introduction.  When  the  stem  is  passed  into 
the  uterus  as  far  as  the  disk,  the  finger  pressed  upon  this,  retains  it  in 
situ  whilst  the  holder  is  withdrawn.  The  two  parts  of  which  the 
stem  is  composed  then  diverge,  and,  adjusting  themselves  in  the  uterine 
cavity,  hold  the  instrument  in  its  place.  The  use  of  this  instrument 
is  twofold :  it  keeps  the  os  externum  open  during  the  healing  of  the 
wound,  and  it  straightens  the  uterus.  It  may  be  removed  after  four 
or  five  days.  This  may  be  done  either  by  catching  the  stem  with  the 
holder,  as  for  introduction,  so  as  to  bring  the  two  parts  together  again, 
or  by  simply  drawing  it  down  by  the  tip  of  the  finger. 

Besults  and  Appreciation  of  the  Operation. — The  operation  as  de- 
scribed, or  as  modified  according  to  the  views  of  different  practitioners, 
has  certainly  now  been  performed  some  thousands  of  times.  The  acci- 
dents that  have  attended  it  are  almost  all  explained  by  the  imperfection 
of  the  methods  adopted,  or  by  the  neglect  of  proper  precautions.  At 
one  time  Professor  Simpson  and  some  others  regarded  the  operation  as  so 
slight,  that  they  did  not  hesitate  to  perform  it  in  their  consulting-rooms, 
sending  the  patients  home  in  cabs  immediately  afterwards.  Bleeding 
and  peritonitis  were  not  uncommon  results  of  this  practice.  I  have 
seen  several  cases  of  chronic  pelvic  cellulitis  arising  in  this  manner; 
and  some  cases  of  fatal  bleeding  are  known  to  have  occurred. 


212  DYSMENOEEHOEA. 

The  wished-for  result  is  not  always  immediate.  In  a  certain  number 
of  cases,  indeed,  the  next  ensuing  menstruation  is  perfectly  easy,  and 
future  imnmnity  is  attained.  But  not  unfrequently,  the  first  period  or 
two  after  the  operation  are  even  more  painful  than  before.  This  may 
be  accounted  for  by  the  congestion  which  remains  after  the  operation, 
and  by  the  extreme  nervous  irritability  of  the  subject.  The  sympa- 
thetic distension  and  pain  in  the  breasts,  a  frequent  concomitant  of  dys- 
menorrhoea,  is  commonly  relieved  or  removed  after  the  operation. 

That  relief  should  not  be  immediate  is  not  surprising,  when  we  con- 
sider the  state  to  which  protracted  suifering  and  impaired  nutrition 
have  usually  reduced  the  patient.  The  balance  of  the  nervous  system 
has  to  be  restored;  every  tissue  in  the  body  wants  regeneration.  For 
this,  time  is  essential.  In  the  great  majority  of  cases,  relief  more  or 
less  complete  is  gradually  established  within  six  or  eight  months,  and 
ultimate  entire  disappointment  is  quite  exceptional.  One  benefit  is  im- 
mediate. Where  there  has  been  great  congestion  or  inflammation,  this 
is  almost  instantly  relieved  by  division  of  the  vessels. 

Success  is  in  proportion  to  the  earliness  of  treatment.  If  carried  out 
whilst  the  patients  are  comparatively  young,  and  within  two  or  three 
years  of  marriage,  the  prospect  of  complete  relief  is  very  great.  But 
even  after  the  age  of  thirty,  success  more  or  less  decisive  is  still  the 
rule.  The  important  point  is  to  operate  before  secondary  changes  in 
the  uterus  and  ovaries  have  been  established. 

As  already  stated,  opinions  are  not  unanimous  as  to  the  value  of  the 
operation.  Before  discussing  adverse  opinions,  I  think  it  not  unreason- 
able to  submit  that  the  vast  number  of  times  the  operation  has  been  per- 
formed aflPords  prima  facie  presumption  that  it  has  often  been  beneficial. 
Had  it  been  no  better  than  one  of  the  numerous  new  remedies  for  intrac- 
table diseases,  continually  surging  up  and  falling  speedily  into  oblivion, 
because  they  failed  to  cure,  it  is  almost  certain  that  incisions  of  the  con- 
tracted OS  uteri,  for  relief  of  dysmenorrhoea  and  sterility,  would  long 
since  have  shared  the  fate  that  waits  upon  failure.  But  there  is  reason 
to  believe  that  the  operation  is  gaining  favor.  And  if  I  may  trust  my 
own  observation,  it  is  not  because  of  any  excessive  pertinacity  of  medi- 
cal men  in  recommending  it,  that  it  is  so  frequently  performed,  as  because 
many  patients  being  relieved  by  it,  others  are  led  to  hope  for  similar 
benefit. 

Amongst  those  who  have  criticized  the  operation  with  most  minute- 
ness and  authority,  stands  Dr.  Scanzoni.^  His  objections  are  partly 
theoretical,  partly  clinical.  They  are  aimed  at  the  operation  as  a  remedy 
for  sterility,  and  as  a  remedy  for  dysmenorrhoea.  Those  conditions  are 
so  frequently  associated  in  nature,  that  it  is  not  easy  to  discuss  them 
apart.  One  argument  for  the  division  of  the  narrow  os  uteri  lies  in 
this,  that  the  narrow  os  obstructs  alike  the  outward  excretion  of  the 
menstrual  fluid  and  the  ingress  of  the  seminal  fluid,  and  hence  the  corol- 
lary that  enlargement  of  the  os  may  be  expected  to  remove  both  diffi- 
culties. Now,  Scanzoni  admits  that  the  dysmenorrhoea  is  frequently 
relieved,    but   contends   that   the    sterility    persists    notwithstanding. 


1  H.  Scanzoni's  Beitrage,  1870> 


INCISION     OF    THE     CERVIX.  213 

Thence,  he  urges  that  far  too  exclusive  importance  is  attached  to  the 
mechanical  hindrances  to  the  meeting  of  the  semen  and  ova.  He  says, 
we  know  as  yet  little  as  to  the  influence  of  the  various  morbid  condi- 
tions upon  the  fertility  of  the  semen  and  ova.  Diseases  of  the  testicle, 
it  is  known,  sometimes  lead  to  the  absence  of  spermatozoa.  May  not 
the  frequent  diseases  of  the  ovaries  lead  to  the  production  of  diseased  or 
defective  ova  ?  Manifold  experience  proves  that,  during  extreme  anaemia, 
conception  does  not  take  place.  Here  is  a  proof  that  in  the  case  of  the 
ovaries,  as  in  that  of  other  glands,  a  bad  condition  of  the  blood  leads  to 
bad  secretions — ova  incapable  of  fructification.  Another  series  of  diffi- 
culties arises  when  we  consider  the  indispensable  locomotion  of  the 
semen  and  of  the  ovum.  It  is  only  necessary  to  call  to  mind  the  fre- 
quent abnormities  of  the  Fallopian  tubes  met  with  in  autopsies,  such  as 
congenital  or  acquired  shortenings,  dislocations,  adhesions,  which  are 
completely  beyond  clinical  diagnosis.  Scanzoni  then  puts  the  case  of 
typical  dysmenorrhoea  with  narrow  os  uteri  and  sterility.  The  os  is 
split,  the  dysmenorrhoea  is  relieved,  but  the  sterility  continues;  and 
asks,  must  it  not  be  admitted  that  there  is  here  a  cause  of  sterility  which 
lies  in  other  and  unknown  conditions? 

This  may  be  freely  granted.  The  cure  of  the  sterility  is  not  nearly 
so  frequent  as  the  cure  of  the  dysmenorrhoea.  Impregnation  is  a  far 
more  complicated  process  than  menstruation.  But  is  the  cure  of  dys- 
menorrhoea unimportant  ?  The  suifering  attending  this  condition  it  is 
which  urges  by  far  the  greater  number  of  patients  to  seek  advice.  The 
sterility  is  with  many  a  secondary  consideration,  or  does  not  so  much 
as  enter  into  their  minds.  In  a  considerable  number  of  cases — I  have 
had  in  my  own  practice  not  a  few — conception  does  follow ;  and  the 
chance,  if  only  a  remote  one,  will  be  esteemed  worth  taking.  It  may, 
then,  be  assumed  as  in  the  highest  degree  probable,  that  the  narrow  os 
uteri  is  one  cause  of  sterility.  It  is  perfectly  logical  and  good  practice 
to  remove  this  cause,  giving  the  patient  the  possible  benefit  of  its  being 
the  only  cause.  Sound  clinical  reasoning  dictates  that  we  should  elimin- 
ate all  the  known  complications  of  a  morbid  state,  and  not  leave  them 
to  harass  a  patient  because  there  may  be  others  which  we  cannot  relieve. 

A  further  reply  to  Scanzoni's  objections  is  justified  by  observation. 
He  insists  upon  the  frequency  of  abnormities  in  the  Fallopian  tubes 
and  ovaries,  met  with  in  autopsies,  which  are  completely  beyond  diag- 
nosis. Now,  it  is  in  a  high  degree  probable  that  some,  if  not  many  of 
these  very  abnormities,  especially  inflammatory  adhesions  and  altered 
conditions  of  the  ovaries,  are  the  consequence  of  the  narrow  os  uteri, 
and  might  have  been  prevented,  had  this  obstruction  to  menstruation 
been  removed  at  an  early  period  of  life.  This  opinion  is  based  upon 
three  orders  of  facts  which  have  come  under  my  observation.  First, 
the  removal  of  sterility,  as  well  as  of  dysmenorrhoea,  is  probable  in 
proportion  to  the  early  removal  of  the  obstruction.  I  have  repeatedly 
seen  women  who  had  passed  one,  two,  or  three  years  of  married  life 
without  pregnancy  conceive  within  two  or  three  months  after  the  opera- 
tion, whilst  women  who  had  remained  sterile  for  ten  years  or  more  were 
cured  of  the  dysmenorrhoea  only.     The  second  clinical  fact  is,  that  I 


214  DYSMEISrOERHGEA. 

have  frequently  observed  symptoms  of  peritonitis  attending  dysmenor- 
rhoea ;  occasionally  I  have  seen  retro-uterine  hsematocele,  both  of  which 
conditions  will  leave  adhesions.  The  third  fact  is,  that  in  single  and 
married  women  who  had  suffered  some  years  from  dysmenorrhoea  at 
first  attended  with  menorrhagia  the  menstrual  discharge  gradually 
tended  to  disappear,  sexual  indiiference  set  in,  the  uterus  underwent 
marked  atrophy ;  in  short,  that  premature  sexual  decrepitude  had  beeu 
produced,  depending  probably  upon  atrophy  of  the  ovary,  which  itself 
was  probably  the  result  of  inflammatory  adhesions,  or  of  the  protracted 
struggle  against  impeded  function. 

It  would  carry  us  far  beyond  reasonable  limits  to  pursue  the  dis- 
cussion, or  to  describe  minutely  the  difterent  proceedings  that  have 
been  advocated.  It  is  desirable,  however,  to  refer  to  the  operation  per- 
formed by  Marion  Sims,  and  to  some  modifications  which  are  thought 
important.  Dr.  Skinner^  thinks  incision  should  be  preceded  by  dila- 
tation by  metallic  sound.  Several  practitioners  concur  in  this  practice. 
Dr.  Skinner  also  contends  "■  that  the  vaginal-portion  ought  on  no  ac- 
count to  be  split  through  and  through."  Dr.  Gustav  Braun^  divides 
the  vaginal-portion  with  Kiichenmeister's  scissors.  He  then  cuts  the 
OS  internum  by  a  blunt-ended,  lancet-shajaed  knife.  He  reports  sixty- 
seven  cases.  The  result  was  favorable  in  fifty -three;  in  eleven  un- 
known ;  in  four  interrupted  by  subsequent  affections  of  the  abdomen  ; 
in  eleven  pregnancy  followed.  Braun's  proceeding  seems  based  upon 
Marion  Sims's.  The  American  surgeon  places  the  patient  on  her  left 
side  ;  introduces  his  duck-bill  speculum  ;  hooks  up  the  os  uteri  by  a 
small  tenaculum  (Fig.  39,  p.  126),  and  thus  draws  the  uterus  gently 
forwards ;  he  then  passes  one  blade  of  a  pair  of  curved  scissors  into  the 
canal  of  the  cervix,  until  the  outer  blade  comes  almost  in  contact  with 
the  reflection  of  the  vagina ;  the  portion  thus  embraced  is  divided  by 
one  stroke  of  the  scissors.  The  opposite  side  is  then  divided  in  like 
manner.  A  narrow-bladed,  blunt-j^ointed  knife  is  then  used  to  divide 
the  spur  of  tissue  left  on  either  side  by  the  springing  back  of  the  scis- 
sors, so  as  to  complete  the  lateral  incisions  "  up  to  the  very  cavity  of 
the  womb."  When  the  bleeding  has  been  stopped,  two  or  three  small 
pieces  of  cotton,  wetted  with  perchloride  of  iron,  are  pressed  in  between 
the  lips  of  the  wound,  and  the  vagina  is  tightly  plugged  below.  That 
this  is  an  effective  operation,  I  do  not  doubt;  but  it  is  unnecessarily 
severe.     Sims  says  the  hemorrhage  is  sometimes  profuse. 

It  is  true  this  can  be  stopped  by  plugging  and  styptics,  but  I  believe 
the  extent  of  the  hemorrhage  is  an  index  of  other  dangers.  It  shows 
that  the  vessels  entering  on  the  level  of  the  os  internum  are  divided,  and 
when  this  is  done  there  is  greater  danger  of  pelvic  cellulitis  and  pya?mia. 
The  scissors  is  a  good  instrument.  For  some  time  after  I  abandoned 
the  two-bladed  metrotomes,  I  used  a  pair  of  scissors,  which  I  had 
specially  designed  for  this  purpose.^  It  is  the  safest  of  all  instruments, 
because  it  can  only  cut  the  infra-vaginal-portion  caught  between  the 

1  Liverpool  Med.  and  Sure;.  Reports,  1865. 

2  Wicn  Med.-Wochenschrift,  18fi9. 
'  '' Obstetrical  Transactions,"  1866. 


VARIOUS    OPERATIONS.  215 

two  blades.  I  would  still  recommend  it  to  those  who  have  not  ac- 
quired by  practice  skill  in  handling  the  single-bladed  metrotome. 

In  cases  where  there  is  decided  flexion  of  the  cervix,  as  well  as  con- 
traction of  the  OS  externum,  Dr.  Sims  modifies  his  operation.  Suppose 
the  case  be  retroflexion,  bilateral  incision  will  not  materially  strengthen 
the  uterus,  and  there  will  remain  constriction  at  the  os  internum  at  the 
angle  of  flexion.  To  bring  the  axis  of  the  uterine  cavity  into  a  direct 
line  with  the  vagina,  he  splits  up  the  anterior  lip  of  the  os  uteri  in  the 
central  line.  This,  by  laying  open  the  lower  part  of  the  cervix  uteri, 
brings  the  os  internum  into  direct  relation  with  the  vagina.  In  the 
case  of  anteflexion,  of  course  it  is  the  posterior  lip  which  is  divided. 

Connected  with  flexions,  and  as  a  presumed  cause  of  them,  Sims  in- 
sists upon  the  frequent  existence  of  small  fibroid  tumors  in  the  anterior 
or  posterior  wall  of  the  body  of  the  uterus.  This  splitting  up  of  the 
anterior  or  posterior  lip  seems  to  be  a  rational  proceeding ;  but  I  have 
been  accustomed  to  treat  the  flexion  in  a  different  manner.  The  com- 
plication, in  my  experience,  is  very  frequent,  and  retroflexion  greatly 
predominates.  To  meet  this,  after  the  bilateral  division  of  the  vagi- 
nal-portion, I  use  a  Hodge  pessary,  occasionally  passing  the  uterine 
sound.  It  has  been  objected  that  the  new  lips  made  by  dividing  the 
vaginal-portion  occasionally  roll  back  so  as  to  cause  a  gaping  con- 
dition of  the  OS.  This  is  apt  to  follow  when  the  splitting  is  excessive. 
It  is  a  reason  for  not  laying  open  the  cervix  quite  to  the  roof  of  the 
vagina. 

Another  objection  specially  urged  by  the  advocates  of  dilatation  by 
tents  is,  that  the  opening  made  by  incisions  frequently  contracts  again, 
whereupon  the  object  of  the  operation  is  frustrated.  This  contraction 
does  sometimes  take  place.  When  it  does,  it  is  desirable  to  repeat  the 
operation,  and  to  obviate  the  tendency  to  contraction  by  wearing  a 
Wright's  intra-uterine  pessary  for  a  day  or  two  during  the  healing  of 
the  wound.  And  these  objectors  should  be  reminded  that  contraction 
always  recurs  after  the  use  of  tents  and  bougies.  The  operation,  as  I 
now  perform  it,  is  as  follows  :  The  necessary  instruments  are, — a  specu- 
lum, the  best  for  the  purpose  being  my  modification  of  Neugebauer 
(see  Fig.  34,  p.  121) ;  a  uterine  sound,  a  Kuchenmeister's  (see  Fig.  37, 
p.  124)  or  my  metrotome  scissors,  or  Simpson's  (see  Fig.  38,  p.  126) 
single-bladed  metrotome,  and  a  Sims's  single  tenaculum-hook  (see  Fig. 
39,  p.  126).  The  patient  lies  in  bed,  undressed,  the  nates  drawn  well 
up  to  the  edge  of  the  bed,  the  thighs  flexed,  the  head  resting  on  a  pillow 
in  the  middle  of  the  bed,  the  shoulders  being  kept  low.  I  have  not 
usually  induced  ansesthesia.  The  operation,  although  annoying,  is  not 
protracted,  and  only  in  rare  cases  very  painful.  Where,  however,  the 
patient  is  very  nervous,  it  is  better  to  give  chloroform  or  ether. 

The  sound  is  introduced  to  take  exact  survey  of  the  direction  of  the 
cervix  and  uterus.  The  speculum  is  then  introduced  so  as  to  bring  the 
vaginal-portion  well  into  the  field.  The  advantage  of  my  speculum  is 
here  seen  in  its  bringing  the  vaginal-portion  forward,  so  that  in  almost 
every  case  it  can  be  touched  with  the  finger.  The  speculum  being 
held  by  an  assistant,  although  I  have  often  performed  the  operation 


216 


DYSMENOEEHGEA. 


Fig.  62. 


without  assistance,  the  plain  blade  of  the  scissors  is  passed  into  the  cer- 
vix from  half  an  inch  to  an  inch,  and  the  part  intervening  between  the 
blades  is  divided  by  a  quick  stroke.  The  blades 
are  then  reversed,  and  the  opposite  side  of  the 
cervix  is  dealt  with  in  like  manner.  Generally, 
if  Kiichenmeister's  scissors  are  used,  the  hooked 
blade  having  secured  the  part  so  as  to  prevent 
it  slipping  back  under  the  stroke,  the  operation 
is  now  completed.  But  if  other  scissors  are 
used,  it  is  desirable  to  hold  the  vaginal-portion 
steady  by  Sims's  tenaculum  during  the  cut.  The 
operation  may  be  done  with  Simpson's  metro- 
tome instead  of  scissors,  and  sometimes  when  it 
is  found  that  the  scissors  have  not  cut  suffi- 
ciently, Simpson's  instrument  may  be  used  to 
complete  the  incisions. 

The  operation,  if  scissors  alone  are  used,  is 
thus  necessarily  limited  to  the  vaginal-portion ; 
that  is,  it  is  by  the  very  conditions  of  the  opera- 
tion kept  within  the  bounds  of  safety.  It  is 
not  often  necessary  to  divide  the  vaginal-por- 
tion quite  up  to  the  angle  of  reflection  of  the 
vagina.  It  is  enough  to  make  a  good  transverse  slit,  or  os  tincse,  which 
shall  give  free  communication  between  the  cavity  of  the  cervix  and  the 
vagina. 

The  part  thus  divided  is  not  very  vascular,  and  it  is  rare  that  bleed- 
ing of  any  importance  occurs.  The  parts  should  be  swabbed  with 
bits  of  sponge  till  bleeding  has  fairly  stopped,  which  it  generally  does 
in  a  few  minutes.  If  it  continue,  a  small  swab  of  sponge,  mounted 
on  a  whalebone  or  other  stem,  or  carried  by  forceps,  and  steeped  in  a 
solution  of  perchloride  of  iron,  may  be  pressed  between  the  lips  of  the 
wound.  The  vagina  is  then  to  be  lightly  plugged  with  strips  of  lint, 
soaked  in  olive  oil,  containing  one  part  in  ten  of  carbolic  acid.  It  is 
convenient  to  attach  a  bit  of  string  to  each  strip  of  lint,  to  facilitate 
removal.     The  plugs  should  be  taken  out  next  day. 

When  there  is  decided  flexion  of  the  uterus,  it  is  useful  to  insert  a 
Wright's  expanding  intra-uterine  pessary.  This  may  be  worn  during 
the  few  days  which  the  patient  spends  in  the  recumbent  posture. 


Shows  the  action  of  Kiich- 
enmeister's  scissors  in  enlarg- 
ing the  OS  uteri  externum. — 
(Half-size.) 


OVAEIAN    DYSMENOERHOEA.  217 


CHAPTER   XXI. 

OVAEIAN  DYSMENOKRHOSA  ;    DYSOOTOCIA  ; 
OOPHORIA  (HYSTERIA);  TUBAL  DYSME]SfORRH(EA. 

When  we  reflect  upon  the  importance  of  the  ovary  in  the  function 
of  menstruation,  upon  the  structure  of  the  organ,  and  the  activity  of 
the  processes  going  on  in  it,  we  shall  not  be  surprised  to  find  that  dys- 
menorrhoea  is  sometimes  due  to  conditions  of  the  ovary.  The  ovary 
is,  as  we  have  seen,  the  primum  mobile  of  menstruation ;  the  first  and 
most  important  part  of  the  function  takes  place  in  its  structure.  This 
part  of  the  twofold  function  is  ovulation  or  ootocia;  the  uterine  part 
consists  in  the  secretion  of  blood.  Difficulty  in  the  ovarian  part  of 
the  function,  then,  means  difficult  ovulation,  a  distinct  thing  from 
difficulty  in  the  secretion  and  excretion  of  the  menstrual  blood,  which 
is  the  duty  of  the  uterus.  It  is  very  important  to  keep  this  distinc- 
tion in  mind.  Dysmenorrhoea  fails  to  express  the  idea  of  difficult 
ovulation  ;  and,  thus  failing,  we  are  apt  to  lose  sight  of  the  clinical 
fact  that  in  many  cases  the  source  of  the  distress  lies  in  the  ovary,  I 
have  therefore  sought  to  designate  difficult  ovulation  by  a  term  in 
accordance  with  medical  nomenclature.  After  consultation  with  my 
colleague,  Dr.  AY.  H.  Stone,  I  venture  to  propose  the  word  "  Dyso- 
otocia."'  There  is  no  doubt  about  the  function  nor  about  the  difficulty 
with  which  it  is  occasionally  performed.  I  hope,  then,  that  I  shall  be 
held  to  be  justified  in  projiosing  a  word  to  describe  it. 

The  clearest  cases  of  ovarian  dysmenorrhoea  are  those  where  there 
is  pain  at  the  menstrual  periods,  and  no  uterus,  or  only  such  an  im- 
perfectly-developed uterus  as  to  be  unfit  for  its  function.  In  these 
cases  the  cause  of  distress  seems,  ex  necessitate  rei,  concentrated  in  the 
ovaries.  I  have  observed  signs  of  local  fulness  with  pain ;  but  the 
chief  distress  has  been  in  the  nervous  centres ;  severe  headaches,  with 
such  mental  disturbance,  marked  by  prostration,  as  to  lead  to  fear  that 
the  mind  would  give  way.  Strange  to  say,  I  have  known  two  cases 
of  this  kind  to  be  almost  completely  relieved  when  a  vagina  had  been 
made  by  dissecting  up,  although  no  menstrual  flow  was  established. 

But  when  the  uterus  and  entire  sexual  apparatus  is  well  developed, 
the  ovaries  still  may  exhibit  the  only  signs  of  periodical  activity.  There 
is  the  monthly  pain  in  one  or  other  iliac  region,  the  increased  nervous 
irritability,  perhaps  general  vascular  excitement  or  tension,  leading 
possibly  to  Schneiderian  epistaxis ;  but  the  uterus  takes  no  obvious 
part  in  the  effiDrt. 

These  cases  show  that  an  attempt  at  ovulation  is  often  made,  and 
that  the  menstrual  effi)rt  is  exhausted  in  this  attempt,  no  uterine  men- 

1  Erom  Svg  and  uotokeu,  to  lay  eggs. 


218  DYSMENOREHCEA. 

struation  occurring.  These  cases  are  usually  classed  under  amenorrhcea  ; 
but,  strictly,  they  should  be  called  cases  of  imperfect  or  abortive  men- 
struation.    They  are  really  very  common. 

A  form  of  ovarian  dysmenorrhoea  which  I  have  noted,  occurs  in  con- 
nection with  commencing  ovarian  disease.  In  many  cases  of  ovarian 
dropsy  I  have  ascertained  that  for  some  time  preceding  the  develop- 
ment of  the  tumor,  or  the  suspicion  of  it,  dysmenorrhoea  has  been  com- 
plained of.  In  some  cases  I  was  able  to  ascertain  that  there  w^as  no 
complicating  uterine  abnormality  to  account  for  the  trouble.  It  seems 
to  me,  therefore,  reasonable,  to  infer  that  the  dysmenorrhoea  was  due 
to  the  morbid  process  going  on  in  the  ovary.  In  other  cases  where 
the  ovarian  tumor  began  at  the  end  of  sexual  life,  dysmenorrhoea  was 
not  complained  of  But  no  doubt  there  are  exceptions  to  both  these 
rules. 

The  cases  described  by  Dr.  Priestley,^  under  the  title  "Intermen- 
strual or  intermediate  dysmenorrhoea,"  should,  I  think,  be  classed  as 
cases  of  ovarian  dysmenorrhoea.  Severe  pain  is  felt  midway  between 
the  periods,  and  commonly  ceases  before  the  flow  sets  in.  The  suifering 
is  referred  to  one  or  other  ovarian  region ;  and  in  three  cases  out  of  four 
referred  to  by  Dr.  Priestley,  marked  tumor,  or  thickening  from  old 
adhesions,  was  found  in  that  locality.  He  conjectures  that  the  pain  is 
due  to  commencing  ovulation-process,  in  ovaries  affected  by  thickening 
of  the  indusium.  I  have  seen  a  considerable  number  of  similar  cases. 
In  some  there  was  uterine  complication,  which  may,  however,  have 
been  secondary. 

The  existence  of  adhesions  or  marked  tumors,  observed  by  Dr. 
Priestley  in  his  cases,  is  by  no  means  necessary  to  the  production  of 
ovarian  dysmenorrhoea.  At  least,  in  the  majority  of  cases  which  have 
come  under  my  observation,  no  such  coniplication  was  present.  Swell- 
ing, indeed,  sometimes  considerable,  of  the  ovary  commonly  attends 
the  process  even  of  healthy  ovulation ;  but  this  is  not  necessarily  in- 
dicative of  recent  or  old  inflammation. 

Sometimes  ovarian  dysmenorrhoea  is  the  expression  of  some  form  of 
oophoritis,  more  especially  of  that  form  which  N^grier  called  ''vesic- 
ulite"  or  inflammation  of  the  follicle.  In  other  cases  there  is  conges- 
tion, swelling,  tension  of  the  entire  ovarian  shell  or  capsule,  producing 
a  kind  of  strangulation  more  or  less  painful  in  the  organ.  In  these 
cases  the  local  symptoms  are  soon  subdued  or  masked  by  various  ex- 
traordinary nervous  phenomena,  usually  designated  as  hysteria. 

The  work  of  ovulation,  like  that  of  pregnancy,  excites,  first,  a  higher 
degree  of  irritability  of  the  cerebro-spinal  centres ;  secondly,  exalted 
tension  of  the  vascular  system ;  thirdly,  if  the  investment  of  the  ovary, 
or  the  follicle  itself,  present  any  obstacle  to  the  free  swelling  and  burst- 
ing of  the  follicle,  or  if  there  be  any  morbid  condition,  as  subacute 
inflammation  in  the  ovarian  structure,  then,  ovulation  being  impeded, 
disordered,  there  is  a  source  of  irritation.  These  conditions  combined 
will  not  unfrequently  issue  in  the  phenomena  called  "  hysteria." 

If  the  jjhenomena  of  dysmenorrhoea,  that  is,  of  the  complex  form,  in 

1  Proceedings  of  Med.-Chir.  Soc,  1871. 


OVAEIAN.  219 

which  there  is  difficult  ovulation  as  well  as  difficult  secretion  and  ex- 
cretion, be  observed  and  recorded  with  precision,  it  will  as  a  rule,  be 
found  that  the  so-called  hysterical  phenomena  occur  early.  They  coin- 
cide with  the  first  part  or  stage  of  menstruation,  that  is,  with  the  ova- 
rian difficulty.  They  appear  before  the  uterine  or  hemorrhagic  stage 
begins ;  and  often  subside  when  secretion  and  excretion  are  established. 
This  history  implies  two  things :  first,  hysterical  phenomena  find  their 
source  or  their  exciting  cause  in  the  ovary,  not  in  the  uterus ;  secondly, 
the  ovary  having  discharged  its  function  soon  undergoes  involution, 
returning  to  quiescence. 

An  objection,  it  must  be  said  a  superficial  one,  has  been  urged,  that 
even  the  most  severe  and  palpable  diseases  of  the  uterus  and  ovaries, 
such  as  cancer  and  ovarian  dropsy,  do  not  evoke  marked  nervous  phe- 
nomena; and  hence,  by  a  false  a  fortiori  argument,  it  is  concluded  that 
disorders  of  less  severity  cannot  evoke  them.  It  is  quite  true  that  dis- 
eases of  the  uterus,  not  only  those  which  are  severe,  but  also  those 
which  are  comparatively  slight,  rarely  of  themselves  call  forth  hysteria 
or  other  nervous  disorders.  During  the  ordinary  state  the  uterus  is  a 
passive  organ ;  it  has  no  great  sensibility.  It  may  be  cut,  cauterized, 
and  otherwise  manipulated.  It  may  be  eaten  away  by  malignant  ulcera- 
tions, without  producing  severe  nervous  phenomena.  During  men- 
struation its  sensibility  awakens,  and  if  the  escape  of  the  ovum  be  hin- 
dered, there  will  be  increased  and  prolonged  hypersemia  and  hypertes- 
thesia  of  the  uterus. 

Difficult  ovulation  is  almost  always  attended  by  increased  afflux  of 
blood,  marked  by  increase  of  bulk  of  the  ovary.  The  ovario-uterine 
vascular  system  is  so  entirely  one,  that  increase  of  uterine  afflux  neces- 
sarily attends.  It  may,  therefore,  be  expected  that  increased  menstrual 
flow  should  be  a  consequence  or  symptom  of  difficult  ovulation.  Gen- 
erally this  is  so.  Menorrhagia  is  often  the  exponent  of  ovarian  dysmen- 
orrhoea.  And  whether  menorrhagia  be  produced  or  not,  some  degree 
of  pain  referred  to  the  uterus  is  often  experienced.  Thus  we  have  com- 
bined the  two  forms  or  elements  of  dysmenorrhoea,  the  ovarian  and  the 
uterine.  If  we  seek  to  analyze  such  cases,  to  resolve  them  into  their 
component  parts,  wx  find  no  great  difficulty.  The  ovarian  distress  al- 
most invariably  manifests  itself  first.  Pain  is  complained  of  in  one  or 
other  iliac  or  inguinal  region,  often  for  days  before  the  flow  appears, 
and  before  the  uterine  distress  is  felt.  In  many  cases  there  is  little  or 
no  uterine  pain ;  and  when  the  flow  appears,  the  ovarian  pain  subsides. 
In  the  case  of  uterine  dysmenorrhoea,  the  pain  complained  of  is  central, 
pelvic,  and  lumbo-sacral. 

In  connection  with  ovarian  dysmenorrhoea  I  may  cite  some  views  of 
Negrier  which  he  deduces  from  striking  clinical  observations.  He 
describes  what  he  calls  the  "  ovarian  temperament."  It  depends  upon 
large  size  and  enei'gy  of  the  ovaries  disposing  to  early  menstruation, 
to  profuse  menstruation,  to  the  persistence  of  the  function  to  a  late 
period  of  life,  and  to  excessive  sexual  passion.  He  finds  evidence  of 
this  ovarian  predominance  in  the  hypersesthetic  temperament ;  in  the 
persistence  of  menstruation  during  the  early  months  of  pregnancy ;  in 
the  quick  return  of  the  function  after  childbirth ;  and  in  dysmenorrhoea, 


220  DYSMENOERHGEA. 

characterized  by  a  sudden  attack  of  acute  pain  in  an  iliac  fossa,  confined 
to  a  space  which  may  be  covered  by  the  pahn  of  the  hand.  This  pain 
is  not  in  paroxysms,  but  permanent ;  it  does  not  resemble  intestinal 
colic,  but  more  that  of  nephritis.  There  is  no  acceleration  of  pulse. 
These  phenomena  recur  at  every  ovarian  rupture.  It  is  not  within 
my  scope  to  trace  the  history  of  hysteria  or  oophoria  in  a  systematic 
manner,  through  all  its  phases.  Although  I  believe  it  is  next  to  im- 
possible for  any  but  those  who  practice  obstetric  medicine  to  appreciate 
correctly  the  causes  and  concomitant  conditions  of  this  malady,  I  am 
far  from  maintaining  that  it  is  to  be  looked  upon  exclusively  in  its 
relations  to  the  generative  organs.  I  think  no  one,  even  amongst  those 
who  neglect  the  study  of  the  disorders  of  these  organs  the  most,  denies 
that  the  association  of  hysteria  with  disordered  conditions  of  these  or- 
gans, is  frequent.  Possibly,  those  who  devote  themselves  almost  ex- 
clusively to  this  study  may  exaggerate  the  importance  of  this  associa- 
tion.    There  may  be  too  much  absolutism  on  both  sides. 

I  hope  to  have  an  opportunity  of  discussing  this  interesting  and 
intricate  subject  elsewhere.  My  present  object  is  simply  to  show  the 
primary  influence  of  the  ovary  in  evoking  certain  nervous  phenomena. 

Iliac  pain  has  long  been  recognized  as  a  frequent  attendant  on  hys- 
teria. There -is  some  divergence  of  opinion  as  to  the  actual  seat  of  this 
pain.  Schutzenberger,  Piorry,  Negrier,  and  Romberg  insist  that  it 
lies  in  the  ovary.  Briquet  says  it  is  only  a  muscular  pain,  a  "  myo- 
dome."  The  pain  of  the  pyramidal  portion  of  the  inferior  extremity  of 
the  rectus  muscle  has  been  mistaken  for  a  uterine  pain ;  and  the  pain 
of  the  lower  portion  of  the  oblique  muscle  answers  to  the  pretended 
ovarian  pain.  Such  is  Briquet's  opinion.  That  muscular  pain  often 
enters  as  an  element  in  these  cases,  I  do  not  doubt,  but  that  this  ex- 
plains the  whole  case  appears  to  me  quite  untenable.  Sometimes  the 
pain  is  very  intense ;  the  patient  cannot  bear  to  be  touched  by  the  bed- 
clothes. It  is  obvious  that  in  these  cases  the  muscles  and  skin  play  a 
part.  There  is  general  hypersesthesia.  But  in  many  of  these  cases, 
emotion  plays  a  part  too ;  the  patient  shrinks  and  cries  out  before  she 
is  touched ;  and  this  shrinking  and  this  superficial  pain  are  commonly 
only  indications  of  an  instinctive  effort  to  protect  the  deeper  structures, 
really  the  seat  of  pain,  from  injury.  This  is  only  one  illustration  of  a 
general  law,  that  suffering  internal  organs  are  protected  by  the  muscles 
over  them  contracting  in  such  a  manner  as  to  screen  them  from  outward 
disturbance. 

At  other  times,  however,  the  pain  in  the  iliac  region  is  not  com- 
plained of  spontaneously,  and  there  is  little  or  no  superficial  muscular 
pain.  The  muscles,  when  relaxed,  may  be  pinched  without  evoking 
pain.  "VVe  must  feel  deeper.  The  pain  is  nearly  fixed  in  one  spot,  that 
spot  being  the  seat  of  the  ovary.  Pressure  here  will,  as  Dr.  Charcot 
says,  when  brought  to  bear  upon  the  ovary,  which  can  be  felt  and  dis- 
tinguished under  the  touch,  cause  a  characteristic  pain,  inducing  painful 
radiations  towards  the  epigastrium,  complicated  sometimes  with  nausea 
and  vomiting ;  and  then,  if  pressure  be  continued,  palpitation,  with 
extreme  frequency  of  pulse,  soon  follows ;  and  lastly,  the  sensation  of 
globus  hystericus  is  developed  in  the  neck.     Charcot  goes  on  to  say 


OVAEIAN.  221 

that  various  cephalic  phenomena  succeed ;  such,  for  instance,  as  when 
the  left  ovary  is  compressed,  intense  wheezing  noises  in  the  left  ear,  and 
loss  of  sight  of  the  left  eye.  If  the  right  ovary  be  compressed,  the  head- 
symptoms  are  noticed  on  the  right  side.  If  pressure  be  pushed  beyond 
this  point,  convulsions  would  break  out. 

The  following  case  related  by  N^grier  is  so  apposite  as  a  typical 
illustration,  that  I  cite  it  in  detail. 

A  lady,  aged  twenty-one,  of  ovarian  temperament,  had  hysteria  from 
fourteen  to  eighteen ;  married  at  nineteen ;  had  abortion  at  fifth  month 
of  pregnancy,  after  riding  on  horseback  at  a  menstrual  epoch ;  free 
hemorrhage  two  months  later.  Suddenly  violent  muscular  contractions, 
with  throwing  back  of  the  spine,  set  in  ;  sharp  involuntary  cries,  sufiPo- 
cating  sensations  attended.  Energetic  pelvic  projection  as  often  as  the 
hand  is  applied  to  the  hypogastrium.  She  had  not  menstruated  since 
abortion.  Pressure  in  the  right  iliac  region  reproduced  a  nervous 
irradiation  towards  the  diaphragm.  This  sensation,  said  the  patient, 
was  exactly  like  that  which  precedes  the  nervous  attacks. 

She  recovered  after  dry  cupping  and  cupping  blood  in  the  iliac  fossa. 

The  "pelvic  projection"  mentioned  by  Negrier,  consists  in  the  throw- 
ing forward  of  the  pelvis.  It  is  a  frequent  and  remarkable  symptom 
of  oophoria. 

Charcot  confirms  the  conclusion  drawn  from  JSTegrier's  and  Schutz- 
enberger's  experiments,  which  show  that  pressure  in  the  ovarian  region 
only  reproduces  artificially  the  same  series  of  phenomena  which  is 
spontaneously  developed  in  hysterical  subjects.  Charcot  points  out 
that  the  hemi-ansesthesia,  the  paresia,  and  contraction  occupy  the  left 
side  when  oophoralgia  is  left,  and  vice  versa. 

In  several  cases  Charcot  demonstrated  that  the  convulsions  of  hys- 
teria could  be  controlled,  resolved  by  firm  pressure  upon  the  ovary. 
Willis,  it  appears,  in  the  seventeenth  century,  was  aware  of  the  power 
of  firm  pressure  by  the  two  hands  in  the  abdomen  in  stopping  a  fit  of 
convulsions. 

Chairou  says  he  knows  a  young  person  in  whom  an  hysterical  fit 
can  be  produced  by  compression  of  the  left  ovary ;  and  Dr.  Tilt  says 
he  knows  a  patient  in  whom  similar  pressure  is  followed  by  uncon- 
sciousness. I  have  myself  on  several  occasions  witnessed  similar 
sequences  of  nervous  phenomena. 

I  feel  a  strong  conviction  that  close  observation  wdll  tend  more  and 
more  to  establish  the  fact,  that  iliac  pain  is  the  most  constant  and  the 
primary  feature  in  hysterical  attacks.  Opponents  of  the  ovarian  theory 
have  too  often  indulged  in  what  seemed  to  them  the  unanswerable  fact, 
that  there  is  no  relation  between  hysteria  and  indubitable  diseases  of 
the  ovary.  It  is  true  that  severe  organic  disease  of  the  ovary  is  not 
often  attended  by  hysteria.  It  is  even  probable,  that  since  severe  dis- 
ease commonly  tends  to  suppress  the  function  of  ovulation,  it  would 
thereby  tend  to  suppress  hysteria.  It  is  not  organic  disease  of  the 
ovary  that  causes  hysteria,  but  that  disorder,  that  difficulty  in  the  per- 
formance of  its  function,  which  is  so  common  in  young  persons. 

Perfect  coincidence  as  to  time  in  the  occurrence  of  ootocia,  and  of  the 
development  of  hysterical  symptoms,  is  not  wanted  to  establish  the 


222  DYSMENORRHOEA. 

truth  of  the  ovarian  theory.  Clinical  observation,  however,  proves 
conckisively  that  the  iliac  pain,  which  is  the  expression  of  dvsootocia, 
in  an  immense  number  of  instances,  is  the  first  condition.  When  once 
the  hysterical  temperament  has  been  thoroughly  established  by  several 
attacks,  the  excitability  of  the  nervous  centres  induced  is  so  great,  that 
it  will  respond  to  the  slightest  peripheral  or  emotional  irritation.  The 
attacks  then  occur  at  other  than  the  menstrual  periods.  It  must,  more- 
over, be  remembered  that  menstruation,  that  is,  the  flow  of  blood,  does 
not  always  coincide  exactly  with  ovulation  or  ootocia.  This  process 
certainly  often  begins  several  days  before  the  uterus  pours  forth  blood ; 
and  in  very  susceptible  persons,  the  proclivity  to  excito-motory  dis- 
turbance is  so  great,  that  even  the  trouble  of  the  early  stages  of  dyso- 
otocia  is  enough  to  bring  forth  the  hysterical  fit. 

When  the  hysterical  habit  has  once  gained  force,  any  physical  or 
mental  fatigue,  or  ordinary  emotion,  may  induce  such  exhaustion  of 
the  nerve-force  that  the  balance  is  disturbed,  and  the  control  of  the 
will,  which  undoubtedly  is  often  sufficient  to  keep  down  a  fit,  is  lost. 
It  is,  however,  a  serious  error,  because,  if  acted  upon,  it  may  lead  to 
cruel  treatment,  to  look  upon  hysteria,  as  some  do,  as  essentially  a 
mental  disorder  characterized  by  moral  perversion.  Some  such  element 
certainly,  in  some  instances,  enters  into  the  field;  and  a  certain  degree 
of  counteractino:  moral  force  from  without  must  be  exerted  in  the  treat- 
ment.  But  intimate  knowledge  of  the  constitution  and  character  of 
many  sufferers  from  hysteria  leaves  a  settled  conviction  on  my  mind, 
that  the  attack  is  utterly  beyond  their  voluntary  control;  that  they 
look  upon  it  with  a  sense  of  pain  and  degradation;  that  they  would 
willingly  conceal  their  infirmity  from  others.  In  persons  of  feeble 
character,  of  little  self-reliance,  eager  for  sympathy,  especially  where 
the  ovarian  excitement  gives  rise  to  an  erotic  feeling,  no  doubt  the 
attack  is  often  promoted  and  encouraged  by  a  perverted  will.  It  is 
difficult  when  witnessing  a  case  of  this  kind  to  repress  the  feeling  that 
a  decided  treatment  of  coercion  would  be  the  most  appropriate.  But 
it  would  be  neither  true  in  science,  nor  morally  justifiable,  to  carry 
this  feeling  into  the  treatment  of  the  numerous  other  cases  in  which 
the  patient  can  no  more  suppress  her  illness  than  can  the  subject  of 
puerperal  convulsions.  Lately  it  has  been  proposed  to  employ  terror 
— the  terror  of  being  strangled  by  violent  compression  of  the  vessels 
of  the  neck — as  a  means  of  dealing  with  these  cases.  I  cannot  look 
upon  this  revolting  practice — for  I  believe  it  has  been  practiced — with- 
out shame  and  humiliation  that  such  ignorance  and  brutality  should 
be  so  far  recognized  as  to  be  discussed. 

Tracing  the  nervous  phenomena  usually  summed  up  as  "hysteria" 
to  ovarian  influences,  Xegrier  proposes  to  substitute  the  word  "ovarie" 
for  "  hysteric."  Agreeing  in  great  measure  with  Xegrier's  views,  I  see 
serious  practical  objection  to  the  particular  word  he  has  selected.  Even 
in  its  French  form  the  word  "ovarie"  is  scarcely  distinct  enough  from 
"ovaire"  or  "ovarite,"  and  in  English  the  word  "ovaria"  is  excluded 
by  its  he'nv^  in  common  use  as  the  plural  of  ovarium.  I  therefore 
propose  the  word  "oophoria,"  which  is  more  correct  etymologically, 
and  convenient  in  relation  to  oophoritis  or  inflammation  of  the  ovary. 


OVARIAN.  223 

N^grier  says  the  ovaries  perform  alternately. 

1.  He  finds  in  one  ovary  a  recently-rnptured  follicle,  and  in  the  op- 
posite, one  coming  forward. 

2.  In  cases  of  dysmenorrhoea  the  suffering  is  sometimes  every  other 
epoch,  the  pain  being  one-sided,  and  in  that  side  which  at  other  times 
has  evinced  local  disease. 

3.  In  women  having  double  uterus  and  vagina,  the  menses  have 
come  from  each  side  alternately. 

The  diagnosis  of  ovarian  dysmenorrhoea  is  made  out  by  the  history, 
the  subjective  signs,  and  the  objective  signs.  Pain  occurs  in  one  or 
both  iliac  regions,  limited  to  a  small  space,  before  the  menstrual  flow 
appears ;  if  the  region  which  is  the  seat  of  pain  be  touched  externally, 
the  abdominal  muscles  become  tense,  so  as  to  screen  the  deep  structures 
beneath ;  if  pressure  be  made  on  the  opposite  side,  although  often  the 
patient  shrinks,  either  from  dread  or  from  a  generally  diffused  hyper- 
aesthesia,  the  pressure  is  borne  with  comparative  ease ;  if  examination 
be  made  by  the  vagina  very  tenderly,  so  as  to  touch  the  os  uteri  with- 
out exerting  pressure  on  either  side  of  the  uterus,  no  marked  pain  is 
elicited  ;  but  if  the  uterus  be  pressed  upwards  or  towards  the  side  where 
the  affected  organ  is  situated,  acute  pain  is  produced ;  if  the  finger  be 
pressed  deeply  in  the  vaginal  roof  towards  the  affected  ovary,  avoiding 
the  uterus,  pain  is  also  elicited ;  if  the  abdominal  muscles  can  be  re- 
laxed, and  sometimes  an  opportunity  is  found  on  deep  expiration  with 
the  thighs  well  flexed,  the  hand  outside  can  be  pressed  down  towards 
the  finger  inside,  so  as  to  grasp  the  tender  ovary  between  them ;  if  the 
like  manoeuvre  be  repeated  with  one  finger  in  the  rectum,  the  ovary 
may  often  be  felt  enlarged,  tumid,  tender,  a  little  lower  than  its  usual 
position,  and  a  little  more  central. 

There  is  another  sign  characteristic  of  ovarian  congestion  which  I 
have  almost  constantly  observed.  It  is  this :  the  body  of  the  uterus 
is  drawn  towards  the  affected  ovary  in  lateri version,  so  that  the  vagi- 
nal roof  on  that  side  is  more  tense  and  full  than  on  the  other.  This 
drawing  together  of  the  uterus  and  affected  ovary  is  no  doubt  due  to 
the  greater  tumefaction  of  the  intervening  tissues,  caused  by  the  more 
active  vascular  process. 

It  is  curious  to  remember  that  Galen  says  lateral  displacement  of  the 
womb  is  often  associated  with  hysteria. 

A  frequent,  if  not  constant,  phenomenon  in  ovarian  dysmenorrhoea 
is  a  swelling  of  the  lower  abdomen,  which  takes  place  about  the  time 
of  the  menstrual  effort.  It  is  due  to  distension  of  the  intestines,  and 
is  the  result  of  a  disturbance  or  metastasis  of  nerve-force,  by  which 
the  intestines  for  a  time  lose  their  tone  or  contractile  energy. 

The  symptoms  above  described  will,  in  many  cases,  be  found  almost 
alone,  that  is,  as  far  as  pelvic  symptoms  are  concerned.  They  will  in 
almost  every  case  be  attended  with  nervous  phenomena,  generally  of 
the  so-called  hysterical  order,  sometimes  by  vomiting,  occasionally 
even  by  convulsions,  generally  by  headache.  The  pulse  is  seldom  much 
accelerated ;  there  is  no  marked  heat  of  skin. 

But  in  a  considerable  number  of  cases  the  symptoms  of  ovarian 
distress  are  accompanied  by  those  of  uterine  distress.     Uterine  ob- 


224  DYSMENOREHCEA. 

structive  dysmenorrhoea,  as  it  is  commonly  called,  but  to  which  I  pre- 
fer the  term,  dysmenorrhoea  from  retention,  complicates  the  ovarian 
dysmenorrhoea.  But  even  in  these  cases  the  ovarian  symptoms  take 
precedence  in  time. 

The  treatment  of  ovarian  dysmenorrhoea: 

The  indications  are,  to  allay  general  and  centric  hypersesthesia,  and 
to  moderate  the  local  ovarian  pain.  The  two  indications  are  carried 
out  at  the  same  time.  It  is  important  to  clear  out  the  bowels,  so  as  to 
take  oif  any  pressure  upon  the  ovaries  which  a  loaded  rectum  may 
cause.  When  the  pain  is  very  great,  and  especially  if  the  pulse  rise, 
and  the  skin  be  hot,  ten  or  twelve  leeches  to  the  iliac  region  will  give 
great  relief.  Two  or  three  leeches  applied  directly  to  the  fundus  of 
the  vagina  are  more  effectual ;  but  this  treatment  is  open  to  serious 
practical  objections.  Indeed,  when  we  consider  that  the  affection  is 
one  that  tends  to  return  every  month,  the  remedy  may  be  found  as 
distressing  as  the  disease ;  and  if  often  repeated,  the  consequent  anae- 
mia and  debility  will  increase  the  hypersesthesia  by  lowering  the 
general  strength.  Now  and  then,  however,  the  affection  has  been 
cured  in  a  comparatively  short  time  by  the  application  of  leeches  out- 
side. Fomentations,  to  which  turpentine  is  added,  or  slight  vesications 
by  chloroform,  may  always  be  used  with  advantage. 

The  general  remedies  consist  chiefly  in  sedatives.  Hoffman's  ano- 
dyne, acetate  of  ammonia,  chloride  of  ammonium,  bromide  of  potassium, 
chloral  hydrate,  and  opiates,  give  valuable  aid.  Opiate  suppositories, 
or  vaginal  pessaries,  are  often  serviceable.  If  convulsions  appear,  the 
inhalation  of  chloroform  should  be  resorted  to,  with  great  discretion, 
however,  lest  we  engender  a  desire  for  its  frequent  use.  Here,  again, 
as  generally  in  the  diseases  of  women  characterized  by  marked  nervous 
phenomena,  alcoholic  stimulants  should  be  allowed  only  in  the  most 
rigorous  moderation,  or  even  absolutely  cut  off. 


Dysmenorrhoea  from  Ohsti'uction  of  Fallopian  Tubes. 

Bernutz  relates  a  case  which  seemed  to  be  of  this  nature.  A  lady 
at  twenty-eight  enjoyed  good  health  till  some  months  before  death ; 
she  then  had  metrorrhagia,  and  was  thought  to  have  a  miscarriage. 
During  a  time  of  severe  mental  trial  she  was  seized  suddenly  with 
violent  pains  in  the  abdomen,  fainting,  and  vomiting.  There  was  then 
no  discharge.  She  soon  sank  with  symptoms  of  internal  hemorrhage. 
Much  blood  was  found  in  the  abdomen  and  pelvis.  The  left  tube 
presented  a  tumor  the  size  of  a  pigeon's  ^gg',  on  its  surface  was  a 
small  transparent  cyst,  covered  with  filaments  of  the  tube.  At  its 
junction  with  the  uterus,  the  tube  was  rendered  impervious  by  a  small 
fibrous  tumor. 


MEMBRANACEA.  225 


CHAPTER  XXII. 

INFLAMMATOKY  DYSMENOERHCEA ;  DYSMENORRHEA 
MEMBRANACEA. 

Inflammatory  dysmenorrhcea  is  not  common  in  single  women. 
The  clearest  examples  are  those  in  which  dysmenorrhoea  follows  on 
suppressed  menstruation,  as  from  the  sudden  shock  of  cold,  injury,  or 
emotion  sustained  during  the  flow.  Under  this  circumstance,  metritis, 
or  at  least  intense  uterine  congestion,  is  very  likely  to  arise ;  and  an 
inflamed  organ  necessarily  performs  its  function,  if  it  be  performed, 
with  pain.  Not  uncommonly  in  these  cases,  pelvic  peritonitis  and 
oophoritis  complicate  the  metritis ;  and  these  conditions  in  themselves 
will  make  menstruation  painful.  The  history  of  the  case,  the  evidence 
of  primary  pelvic  inflammation,  and  of  secondary  dysraennorrhoea,  ex- 
plain the  nature  of  the  affection.  In  some  of  these  cases  there  is  not 
only  some  degree  of  chronic  metritis  persisting,  but  as  sequelae  of  the 
peritonitis,  adhesions  may  remain  which  impede  the  mobility  of  the 
uterus,  and  even  drag  it  out  of  place.  Local  examination  confirms  the 
diagnosis  supplied  by  the  history. 

In  these  cases  the  appropriate  treatment  is  to  apply  six  to  ten  leeches 
to  the  groin,  or  two  to  the  cervix  uteri ;  to  use  warm  hip-baths  con- 
taining Vichy  salts ;  to  administer  salines  and  sedatives.  If  the  peri- 
tonitic  complication  be  severe,  it  is  desirable  to  give  small  doses  of 
calomel  and  opium  for  two  or  three  days.  The  rectum  should  be 
cleared  out  by  an  enema  of  gruel  and  olive  oil;  but  all  purgatives  which 
disturb  parts  which  ought  to  be  at  rest,  should  be  carefully  avoided. 

Inflammatory  dysmenorrhoea  is  well  exemplified,  although  not  per- 
haps in  its  purest  form,  in  those  cases  where  metritis,  with  perimetritis 
and  soDie  degree  of  fixing  of  the  uterus,  spring  up,  and  persist  after 
labor  or  abortion.  In  many  of  these  cases  there  is  a  clear  history  of 
freedom  from  dysmenorrhoea  until  after  labor;  henceforth  the  menstrual 
function  is  performed  with  pain.  The  pain  comes  on  with  the  flow, 
which  is  often  profuse  and  hemorrhagic,  lasting  for  six  days  or  even  a 
fortnight.  The  pain  is  referred  to  the  seat  of  the  uterus,  whence  it 
radiates  to  the  back.  The  treatment  resolves  itself  into  that  of  the 
abnormal  condition  of  the  uterus,  and  surrounding  structures.  The 
further  history,  then,  of  this  form  of  dysmenorrhoea  will  be  discussed 
when  describing  the  conditions  of  which  it  is  a  symptom  or  consequence. 

The  Dysmenorrhwa  memhranacea  may  be  classed  under  the  inflam- 
matory kinds.  It  is  often  a  very  obstinate  affection.  The  pathogno- 
monic feature  is  the  discharge  of  a  membrane,  sometimes  in  shreds, 
sometimes  representing  a  cast  of  the  cavity  of  the  body  of  the  uterus. 
A  case  is  graphically  related  by  Morgagni.     The  real  nature  of  these 

15 


226  DYSMENOEEHCEA. 

r 

membranes  was  not  clearly  understood  until  it  was  described  by  Dr. 
Oldham.^  They  had  long  been  regarded  as  casts  formed  by  exudations 
of  lymph,  like  those  of  croup.  They  are  so  described  by  Montgomery, 
R.  Ferguson,  Churchill.  Oldham  distinctly  enunciated  the  proposition 
that  these  membranes  were  formed  under  the  ovarian  stimulus  ;  and 
that  they  were  formed  by  the  uterine  glands — that  they  were,  in  short, 
menstrual  decidua. 

Oldham's  observation  was  speedily  confirmed  by  others.  Professor 
Simpson^  described  the  membrane  as  resembling  the  decidua  vera.^ 
Bernutz  cites  three  cases  from  Boivin  and  Duges,  in  which  casts  or 
cysts  were  expelled  from  the  uterus,  in  order  to  prove  that  the  affection 
described  by  Oldham  had  been  previously  known  in  France.  But  we 
have  already  seen  that  a  case  of  a  shed  membrane,  exactly  resembling 
a  cast  of  the  uterus,  had  been  accurately  described  by  Morgagni ;  and 
the  other  authors,  whose  names  are  cited  above,  distinctly  refer  to  the 
disease.  It  is  not,  then,  the  discovery  of  a  particular  variety  of  dys- 
menorrhoea,  distinguished  by  the  shedding  of  a  membrane,  which  con- 
stitutes Oldham's  merit ;  it  is  the  discovery  that  this  membrane  was 
not  simply  an  exudation-cast  of  the  lining  membrane  of  the  uterus,  but 
the  lining  membrane  itself.  Oldham's  priority  in  this  respect  still  re- 
mains untouched. 

But  here,  as  is  constantly  happening  in  the  history  of  medicine,  we 
have  an  instance  of  the  disposition,  at  once  and  absolutely  to  exclude 
the  hitherto  existing  theory  of  a  disease,  and  to  replace  it  as  absolutely 
by  the  last  new  theory  brought  forward.  It  is  too  often  forgotten  that 
both  may  be  true,  as  expressing  the  nature  of  certain  cases ;  and  that 
neither  may  be  true,  as  expressing  the  character  of  all  cases.  The  new 
fact,  that  the  membrane  expelled  is  the  mucous  membrane  of  the  uterine 
cavity,  is  undoubtedly  true,  but  I  am  in  a  position  to  affirm  from  my 
own  observation  that  the  membrane  expelled  in  some  cases  of  dysmen- 
orrhcea  consists  essentially  of  fibrin  and  mucus,  and  does  not  contain 
the  elements  of  mucous  membrane.  It  is  important  then  to  bear  in 
mind  that  the  membranes  associated  with  dysmenorrhoea  are  not  ail  of 
one  kind. 

The  first  kind  may  be  defined  as  the  exfoliated  mucous  membrane 
of  the  uterus.  All  the  elements  of  this  membrane  may  be  recognized 
by  the  microscope.  When  voided  they  may  be  entire,  in  which  case 
their  source  and  nature  are  easily  recognized.  They  are  then  seen  as 
three-cornered  bags,  somewhat  longer  in  one  direction,  having  an  irregu- 
lar opening  at  each  angle,  the  opening  at  the  smaller  end  or  space  being 
larger  than  the  two  others.  This  lower  opening  corresponds  with  the  os 
internum  uteri,  the  other  two  with  the  ostia  of  the  Fallopian  tubes.  The 
membranes  are  rough,  ragged  on  the  outer  surface,  and  smooth  on  the  in- 
side. In  size  they  are  about  an  inch  long,  and  a  little  less  in  width,  that 
is,  generally  somewhat  in  excess  of  the  normal  proportions  of  the  cavity 

1  London  Medical  Gazette,  April  17th,  1846. 

2  Edinb.  Monthly  Journ.  of  Med.  Sc,  Sept.,  1846. 

3  It  is  to  be  regretted  that  even  in  the  collected  edition  of  Professor  Simpson's 
works,  published  in  1871,  his  memoir  is  reprinted  without  any  reference  to  Dr. 
Oldham's  prior  publication. 


MEMBEANACEA.  227 

of  the  body  of  the  uterus.  Under  the  microscope,  the  distinctive  element 
of  the  uterine  mucous  membrane,  namely,  the  utricular  glands,  is  made 
manifest.  It  may  be  said  that  the  identification  of  this  membrane  as 
mucous  membrane  was  a  natural  consequence  of  the  identification  of  the 
decidua  of  pregnancy  as  mucous  membrane.  This  decidua  had  already 
gone  through  the  same  phases  of  theory,  that  is,  it  was  long  looked  upon 
as  a  simple  exudation  from  the  inner  uterine  surface,  analogous  to  the 
fibrinous  effusions  of  inflammation  or  croup,  and  it  was  ultimately 
recognized  as  the  highly  developed  mucous  membrane.  The  applica- 
tion of  this  knowledge  of  the  true  nature  of  the  decidua  gravida  to  the 
study  of  the  deciduous  membrane  of  dysmenorrhoea,  might  be  directly 
suggested  by  the  demonstration  of  Coste  that  the  uterine  mucous  mem- 
brane at  the  epoch  of  menstruation  assumed  a  development  strictly  an- 
alogous to  that  which  it  assumed  on  the  advent  of  gestation.  This 
similarity  suggested  to  Virchow  the  name  "  decidua  menstraalis"  for 
the  dysmenorrhoeal  membrane ;  and  this  name,  although  rather  indica- 
tive of  a  constant  or  normal  state,  than  of  a  pathological  one,  it  is  con- 
venient to  retain.  The  decidua  menstrualis,  then,  may  be  expected 
to  present  characters  like  those  of  the  decidua  of  early  pregnancy. 
And  this  similarity  is  so  close  that  some  observers  have  impugned  the 
existence  of  the  decidua  menstrualis,  and  contend  that  all  membranes 
presenting  the  characters  of  decidua  are  really  the  jjroduct  of  concep- 
tion ;  that,  in  short,  the  so-called  dysmenorrhoeal  membrane  is  nothing 
but  the  issue  of  an  early  abortion.  This  view  was  distinctly  enunciated 
by  Dr.  Hausmann,^  who  based  his  conclusions  on  the  examination  of 
specimens  furnished  by  Martin  and  Virchow.  The  discharge  of  the 
membrane  at  the  menstrual  epoch  is  not,  he  says,  constant ;  it  is  often 
a  few  days  in  arrear ;  the  expulsion  begins,  as  a  rule,  from  six  to  twenty- 
four  hours,  sometimes  several  days,  after  the  beginning  of  hemorrhage, 
and  always  under  forcing  pains.  The  several  causes  of  this  abortion 
and  of  the  consequent  expulsion  of  the  decidua,  are  not  yet  known,  but 
probably  the  premature  destruction  of  the  embryo  is  the  first  factor. 
The  logical  prophylactic  deduction  from  this  theory  is  simple  abstinence 
from  sexual  intercourse  for  several  months.  Hausmann  cites,  amongst 
other  arguments,  a  case  from  Tyler  Smith,  which  if  it  be  admitted  as 
typical,  would  indeed  furnish  strong  evidence  in  favor  of  the  abortion 
theory.  A  woman  whilst  single  was  healthy;  from  the  time  of  mar- 
riage to  the  death  of  her  first  husband  she  passed  membranes  at  irreg- 
ular intervals ;  became  free  whilst  a  widow ;  and  again  discharged  these 
membranes  six  months  after  second  marriage. 

To  accept  this  theory,  that  the  menstrual  decidua  is  simply  an  abor- 
tion, may  be  to  subject  the  patient  to  an  impeachment  of  her  character. 
If  the  membrane  be  the  result  of  sexual  intercourse,  the  discharge  of 
one  by  a  single  woman,  or  by  one  living  apart  from  her  husband,  must 
be  taken  as  proof  of  unchastity.  It  therefore  behooves  us  to  examine 
the  subject  with  the  utmost  care  before  coming  to  a  final  and  absolute 
conclusion. 

1  "  Monatsschrift  fiir  Geburtskunde,"  1868. 


228  DYSMENOREHCEA. 

Has  the  dysmenorrhoeal  membrane  ever  been  observed  where  absence 
of  sexual  relations  is  undoubted  ?  In  attempting  to  reply  to  this  ques- 
tion, it  is  essential  that  the  structure  of  the  membrane  have  been  accu- 
rately determined  by  the  microscope.  Premising  this  condition,  we  may 
put  the  question  in  another  form — Has  a  case  been  observed  in  which, 
there  being  absence  of  sexual  relations,  a  membrane  has  been  expelled 
bearing  the  distinctive  character  of  uterine  mucous  membrane?  I  put 
the  question  in  this  form,  because  I  think  it  may  be  admitted,  in  limine, 
without  prejudicing  the  main  question,  that  membranes,  of  which  the 
chief  constituent  is  fibrin,  are  passed  quite  independently  of  impregna- 
tion. Some  of  these  fibrinous  casts  are  blood-clots  which,  compressed 
in  the  uterine  cavity,  have  lost  more  or  less  of  the  red-globules ;  and 
on  the  surface,  especially,  have  assumed  a  pale  and  membranous  appear- 
ance. Generally,  however,  these  altered  blood-masses  are  more  or  less 
solid  ;  that  is,  they  present  no  cavity,  or  if  there  be  one,  it  is  filled  with 
blood,  fluid  or  coagulated.  These  casts  or  clot-moles  are  not  very  un- 
common accompaniments  of  dysmenorrhoea.  There  is  no  doubt  of  their 
being  shed  independently  of  impregnation,  or  even  of  sexual  connection. 
But  they  are  certainly  more  common  in  women  who  have  had  children, 
and  who  continue  to  be  subject  to  sexual  connection.  The  natural 
monthly  shedding  of  the  uterine  mucous  membrane,  instead  of  taking 
place,  as  in  the  usual  way,  by  disintegration,  so  that  the  elements  escape 
gradually  as  detritus,  mingled  with  the  menstrual  blood,  may  be  effected 
by  a  more  rapid  and  violent  process.  In  this  case  we  shall  find  distinct 
shreds,  perhaps  an  entire  cast,  composed  of  fibrinous  fibrillse,  of  fibre- 
cells,  numerous  mucous-globules,  and  epithelium-cells.  In  the  case 
from  which  the  figure  (No.  64)  is  taken,  the  subject  had  had  children, 
and  suffered  severely  from  menorrhagia  and  dysmenorrhoea.  I  believe 
this  form  of  membrane  is  restricted,  not  indeed  absolutely,  but  with 
rare  exceptions,  to  women  leading  a  married  life. 

It  is  quite  conceivable  that  the  uterine  mucous  membrane,  having 
undergone  an  unusually  full  menstrual  development,  may  be  cast  off 
even  more  completely  than  in  the  preceding  case.  We  should  then 
have  the  typical  contested  decidua  menstrualis.  The  inner  side  would 
exhibit  the  fine  points  or  holes  of  the  orifices  of  the  utricular  glands, 
and  the  outer  side,  the  ragged  flocculent  appearance  which  is  commonly, 
but  not  always,  seen  in  early  aborted  ova.  It  does  not  consist  of  the 
entire  mucous  membrane  of  the  uterus.  The  outer  layer  of  the  mucous 
membrane,  with  the  blind  extremities  of  the  uterine  glands,  remains 
behind.  The  decidual  membrane  contains  the  normal  elements  of  the 
mucous  membrane,  the  ciliated  epithelium,  the  glands,  the  vessels  and 
connective  tissue ;  the  vessels  and  connective  tissue  are  hypertrophied  ; 
the  glands  are  elongated  and  widened.  If  it  be  admitted,  and  observa- 
tions in  point  are  now  so  numerous  and  authentic  that  it  can  scarcely 
be  disputed,  that  the  mucous  membrane,  under  simple  ovarian  menstrual 
excitation,  does  undergo  a  high  degree  of  development  not  distinguish- 
able from  the  decidua  of  early  pregnancy,  it  must  also  be  admitted  as 
possible  that  the  mucous  membrane  so  developed  may  be  cast  off. 
Moreover,  that  the  presence  of  an  ovum  in  the  uterus  is  not  necessary 
for  the  development  of  a  membrane  having  all  the  characters  of  the 


MEMBRAXACEA.     .  229 

decidua  of  pregnancy,  is  proved  by  the  formation  of  a  decidua  in  utero 
in  cases  of  tubal  gestation. 

Rokitansky  distinctly  says,  when  describing  the  characters  of  a 
membrane  submitted  to  him  by  Mandl,  "The  development  of  the 
mucous  membrane  is  in  excess  of  its  usual  menstrual  degree.  It  is  not, 
however,  connected  with  conception."  It  does,  hoAvever,  occur  in 
women  who  have  had  children.  Courty  relates  in  full  a  case  of  a  girl 
who  passed  membranes  at  her  periods.  On  one  occasion  he  extracted 
one  from  the  os  uteri  by  forceps,  through  a  small  speculum  carefully 
manipulated,  so  as  not  to  break  down  a  virginal  hymen.  This  seems 
an  unequivocal  case. 

Another  form  of  cast  appears  to  consist  purely  of  fibrin.  These 
come  in  shreds,  or  in  one  piece  representing  the  shape  of  the  uterine 
cavity.  Under  the  microscope,  nothing  but  the  fibrillar  arrangement 
of  fibrin,  interspersed  with  mucous  corpuscles,  is  seen.  In  some  cases 
of  endometritis  it  would  seem  eitlier  that  a  layer  of  fibrin  may  be  effused, 
or  that  the  raucous  secretion,  rendered  more  tenacious  by  retention  and 
by  fibrinous  matter,  may  form  a  distinct  layer  on  the  surface  of  the 
Qiucous  membrane.  Such  a  membrane  may  be  independent  of  impreg- 
nation, but  being  associated  with  chronic  metritis,  it  is  rarely  seen  in 
women  not  subject  to  sexual  connection.  At  the  menstrual  epoch  the 
chronic  metritis  is  intensified,  and  may  deserve  the  name  given  to  it  by 
H.  Huchard^  of  "  menstrual  metritis.''^ 

In  some  cases  the  albuminoid  secretion  from  the  cervix  uteri,  which 
is  especially  copious  in  endocervicitis,  may,  entangling  a  lesser  propor- 
tion of  epithelium,  produce  a  tenacious  membrane  less  solid  than  the 
preceding,  but  of  a  similar  character.  This  may  occur  in  single  as 
well  as  in  married  women.  The  mucous  plasma  thus  condensed, 
assumes  very  much  the  appearance  of  fibrillse. 

Shreds  of  membrane,  mostly  very  small,  are  frequently  passed  when 
there  is  malignant  disease  of  the  uterus.  These  are  the  result  of  super- 
ficial disintegration  or  necrosis  of  the  diseased  structures.  They  are 
not  likely  to  be  mistaken  for  dysmenorrhoeal  membranes.  They  differ 
in  being  mostly  minute  in  size,  and  in  being  attended  by  the  turbid, 
greenish,  watery  discharges  characteristic  of  cancer.  I  have  seen  shreds 
of  this  kind  brought  aAvay  from  the  interior  of  the  uterus  by  the  small 
sponge-probang  when  the  disease  affects  the  cavity. 

Raciborski  points  out^  that  the  mucous  membrane  of  dysmenorrhoea 
may  be  distinguished  from  the  decidua  of  early  abortion.  The  dys- 
menorrhoeal membrane  is  generally  in  shreds,  thin  and  membranous, 
triangular,  and  showing  the  orifices  of  the  tubes  and  os  internum  uteri. 
It  is  always  expelled  at  a  menstrual  epoch.  On  the  other  hand,  the 
aborted  decidua  is  generally  thicker,  blood  being  extravasated  in  the 
substance ;  in  shape  it  is  more  ovoid ;  the  tubal  orifices  are  not  easily 
made  out;  and  it  is  generally  passed  after  a  period  has  been  suspended. 

Shreds  of  a  membranous  appearance  may  be  passed  from  the  vagina 
at  intermenstrual  periods,  which  do  not  necessarily  come  from  the 
uterus.     Thus  the  ordinary  exfoliation  of  epithelium  which  takes  place 

'  Gazette  des  Hopitaux,  1870.  2  Ti-aite  de  la  Menstruation. 


230  DYSMENORRHCEA. 

from  the  os  uteri  may,  under  a  condition  of  subacute  inflammation,  be 
so  rapid,  that  the  throwing  off  of  epithelium-cells  exceeds  the  propor- 
tion of  mucus  necessary  to  maintain  fluidity.  In  such  a  case  there  is 
formed  a  layer  of  whitish  material  which  covers  the  mucous  membrane, 
resembling  a  diphtheritic  membrane.  When  analyzed  by  the  micro- 
scope, this  is  seen  to  consist  almost  entirely  of  pavement  epithelium- 
cells  and  mucous  globules.  I  have  not  seen  this  in  virgins,  but  the 
possibility  of  its  occurrence  cannot  be  excluded. 

Under  peculiar  puerperal  states  also,  the  vulva,  vagina,  and  perhaps 
the  uterus,  may  be  covered  with  a  diphtheritic  membrane,  closely  re- 
sembling that  which  covers  the  fauces  in  diphtheria. 

I  mention  one  circumstance,  to  warn  against  a  possible  fallacy. 
When  women  suffering  from  leu corrhoea  are  using  astringent  injections, 
as  of  zinc  or  alum,  the  albuminoid  mucus  is  coagulated  by  the  injec- 
tion, and  comes  away  in  shreds.  The  patients  say  it  brings  away 
"bits  of  flesh  or  skin." 

Dr.  Arthur  Farre  has  described'  cases  in  which  complete  casts  of 
the  vagina  were  passed.  These  were  distinguished  from  uterine  mem- 
branes by  their  having  the  exact  form  of  the  vagina,  by  the  absence  of 
the  characters  of  the  uterine  mucous  membrane,  and  by  not  being  cast 
under  symptoms  of  dysmenorrhoea.  The  drawing,  Fig.  63,  is  taken 
from  a  specimen  of  this  kind  in  St.  Thomas's  Museum. 

It  should  be  borne  in  mind  also  that  the  superficial  layer  of  the 
vaginal  mucous  membrane  is  liable  to  be  exfoliated  under  the  applica- 
tion of  perchloride  of  iron.  Thus,  I  possess  a  very  complete  cast  of  the 
vagina,  showing  all  the  rugae,  which  was  shed  after  several  intra-uterine 
injections  of  this  styptic  to  arrest  obstinate  metrorrhagia.  This  mem- 
brane, like  other  compressible  substances  in  the  vagina,  was  not  ex- 
pelled, but  got  rolled  up  in  a  ball  in  the  posterior  vaginal  cul-de-sac, 
whence  it  was  brought  away  by  the  finger.  It  escaped  detection  by 
the  speculum.  The  surface  of  the  vagina  and  os  uteri  were  pale,  and 
very  smooth.  A  single  injection  is  not  likely  to  cause  this  exfoliation, 
unless  it  be  used  of  nearly  concentrated  strength,  as  in  a  case  related 
by  Dr.  Tessier,  who,  in  a  case  of  profuse  non-puerperal  flooding,  in- 
troduced into  the  vagina  a  piece  of  charpie,  charged  with  pure  per- 
chloride of  iron.  The  plug  was  removed  in  forty-eight  hours.  On 
the  seventeenth  day  a  piece  of  mucous  membrane  was  discharged.  The 
patient  had  a  slow  convalescence,  and  great  contraction  of  the  vagina 
iollowed.  The  perchloride  had  acted  as  a  powerful  caustic,  producing 
a  slough  of  the  mucous  membrane.^  To  avoid  this  caustic  action,  two 
things  are  necessary :  first,  use  solutions  not  stronger  than  one  in  ten ; 
secondly,  thoroughly  oil  the  vagina  before  injecting. 

We  must  then,  a  'priori,  admit  the  possibility  of  the  casting  of  a 
menstrual  decidua,  in  the  form  of  a  membrane.  But  it  must  be  re- 
served for  extended  clinical  observation  and  critical  research,  to  de- 
termine the  frequency  of  the  detachment  of  the  menstrual  decidua  en 
masse,  independently  of  sexual  relations. 

I  must  declare  that  the  greater  number  of  membranous  structures 

'  Beale's  "Archives."  2  Gazette  des  Hopitaux,  18G9. 


MEMBRA  NACEA. 


231 


discharged  in  dysmenorrhoeal  eases  which  I  have  seen,  occurred  under 
the  conditions  specified  by  Hausmann,  that  is,  the  subjects  were  lead- 
ing a  married  life,  and  the  menstruation  had  been  some  days  in  arrear. 
At  the  same  time  we  must  bear  in  mind  that  no  aggregate  of  cases, 
however  large,  in  which  this  association  was  verified,  can  absolutely 
exclude  the  possibility  of  the  discharge  of  a  dysmenorrhoeal  membrane 
by  virgins.     Recognizing  this  possibility,  we  must,  I  think,  go  further, 


Fig.  63. 


Fig.  64. 


Fig.  63.— Exfoliated  mucous  membrane  of  the  vagina.    (G.  G.  5,  St.  Thomas's  Museum— ad.  nat.) 
Fig.  64. — Uterine  mucous  membrane  shed  entire,  laid  open,  showing  interior  cavity  smooth.    (St. 

Thomas's  Museum,  G.  G.  4,  nat.  size.) 
At  upper  part  are  seen  numerous  points,  the  openings  of  glands;  on  the  outer  surface  are  slight 

ragged  projections. 


and  affirm  that  we  cannot,  without  imminent  risk  of  falling  into  sci- 
entific error  and  unjust  suspicions  of  the  chastity  of  the  patient,  admit 
that  any  structural  character  of  a  membrane  cast  from  the  uterus,  short 
of  the  detection  in  it  of  chorion-villi,  is  proof  of  impregnation.  And 
it  must  be  remembered  that  chorion-villi  may  be  simulated  by  the 
ducts  of  the  utricular  glands ;  and  that  it  requires  some  experience  and 
care  to  distinguish  them.  The  epithelial  cells  of  the  utricular  glands 
difPer  from  the  cells  which  surround  the  chorion-villi ;  the  outline  of 
the  gland-casts  is  less  defined;  and  these  do  not  present  the  pyriform 
buddings  which  are  so  characteristic  of  the  early  chorion. 

The  Symptoms.— The  presence  of  inflammation  as  a  necessary  ele- 
ment has  been  doubted.  But  there  can  be  no  doubt  as  to  the  general 
presence  of  congestion  and  hyperplasia.  It  may  be  doubted  whether 
a  single  case  has  occurred  in  which  some  morbid  condition  of  the  uterus 
was  not  coincident.     There  is  almost  always  extreme  tenderness  of  the 


232  DYSMENOERHOEA. 

uterus,  on  touching  the  vaginal-portion  or  the  body  of  the  organ  ;  and 
increased  bulk  of  the  uterus  is  discovered  by  combined  intra-vaginal 
and  abdominal  palpation.  Dyspareunia  and  sterility  are  almost  con- 
stant complications.  The  tendency  to  rapid  morbid  hyperplasia  of  the 
uterine  mucous  membrane  seems  to  unfit  this  structure  for  the  forma- 
tion of  healthy  gravid  decidua,  while  the  morbid  congestion  and  irri- 
tability of  the  muscular  wall  dispose  the  uterus  to  premature  contrac- 
tion, and  to  cast  off  its  contents. 

The  process  of  detachment  of  the  morbid  mucous  membrane  is  vio- 
lent, and  not  the  slow  result  of  gradual  exfoliation.  Exudation  of 
fluid,  serum,  sometimes  blood,  takes  place  between  the  inner  uterine 
wall  and  the  layer  of  mucous  membrane  which  is  to  be  thrown  off; 
then,  spasmodic  contractions  or  colics  of  the  uterus  being  set  up,  the 
detachment  and  expulsion  are  completed. 

The  symptoms  are  in  harmony  with  this  view.  Pain,  pelvic,  abdom- 
inal, and  inguinal,  precede  the  menstrual  flow  by  several  days.  There 
is  bearing-down  pain,  with  sense  of  increased  fulness  and  weight  in  the 
rectum,  frequently  causing  tenesmus  both  of  the  rectum  and  of  the 
bladder.  A  painful  sensation  of  gnawing,  extending  to  the  umbilicus 
and  epigastric  region,  has  been  complained  of  in  several  cases.  The 
pain  is  intensified,  assuming  an  expulsive  labor-like  character  when 
the  flow  sets  in,  and  is  so  continued  from  twenty-four  to  forty-eight 
hours,  when  the  membrane  is  usually  expelled.  The  pain  then  abates; 
but  frequently  the  discharge  of  blood  is  profuse,  and  lasts  for  some 
days  longer.  When  this  has  ceased  the  patient  rallies  for  a  time,  to  be 
again  cast  down  by  the  recurrence  of  a  similar  train  of  events.  It  is 
not,  however,  every  menstrual  period  which  is  attended  by  the  expul- 
sion of  casts.  Sometimes  a  period,  marked  by  less  severe  pain  and 
less  hemorrhage,  occurs.  It  deserves  to  be  carefully  observed  how  far 
these  intermissions  correspond  with  the  suspension  of  sexual  intercourse. 
Dr.  Rigby  says  oophoritis  is  not  seldom  the  result  or  concomitant 
of  this  form  of  dysmenorrhcea.  According  to  the  degree  of  nervous 
susceptibility  and  general  impairment  of  health  of  the  individual, 
various  degrees  and  forms  of  hysterical  and  other  nervous  derange- 
ments will  manifest  themselves. 

The  treatment  of  dysmenorrhcea  membranacea  will  of  course  be  greatly 
governed  by  the  view  we  take  of  the  pathology  of  the  affection.  If 
we  conclude  that  the  essential  factor  is  sexual  intercourse,  especially  if 
involving  im])regnation,  the  main  treatment  is  obviously  prophylactic. 
Abstinence,  that  is,  physiological  rest  for  a  time,  should  be  dictated. 
We  then  gain  time  and  opportunity  for  treating  the  morbid  conditions 
of  the  system  and  of  the  generative  organs. 

The  survey  we  have  taken  of  the  affection  almost  precludes  the  idea 
that  the  menstrual  membranes  are  cast  by  the  healthy  uterus.  It  fol- 
lows that  we  must  carefully  study  the  physical  condition  of  the  uterus, 
and  direct  treatment  to  the  removal  of  the  complicating  diseases. 

What  are  the  best  local  applications?  It  is  clear  that  the  origin  of 
the  membranes  being  the  lining  membrane  of  the  cavity  of  the  uterus, 
our  remedies  must  be  applied  there.  We  can  only  act  very  slowly  in- 
deed, if  at  all,  if  we  trust  to  the  principle  of  derivation  by  limiting  the 


MEMBEANACEA.  233 

application  of  remedies  to  the  cervix.  If  there  is  a  syphilitic  taint  I 
would  advise  the  use  of  a  mercurial  vapor-bath,  using  a  bath-speculum 
to  enable  the  vapor  to  enter  the  vagina.  To  the  inner  cavity  of  the 
uterus  we  may  apply  nitrate  of  silver,  iodine,  bromine,  or  sulphate  of 
zinc.  These  are  best  applied  in  the  solid  form.  By  using  the  instru- 
ment I  have  devised  for  this  purpose,  a  stick  of  sulphate  of  zinc  or 
other  remedy  can  be  readily  passed  into  the  uterine  cavity  without  the 
aid  of  the  speculum,  and  without  any  exposure ;  or  the  iodide  of  mer- 
cury may  be  applied  in  the  form  of  ointment  by  my  instrument. 
(See  Fig.  44,  p.  129.)  The  application  should  be  repeated  every  five 
or  six  days. 

Mandl  speaks  favorably  of  chlorate  of  potash,  as  this  remedy  is 
known  to  possess  a  decided  influence  on  the  liquefaction,  degeneration, 
and  resorption  of  epithelial  growths  and  pseudo-membranous  exuda- 
tions of  the  mucous  membrane.  In  the  case  he  narrates,  benefit  at- 
tended the  use  of  this  substance. 

If  nitrate  of  silver  be  used,  it  should  be  reduced  by  using  three- 
grain  sticks,  made  by  fusing  together  equal  proportions  of  nitrate  of 
silver  and  nitrate  of  potash.  If  there  be  retroversion  or  retroflex- 
ion, as  is  not  uncommon,  this  must  be  corrected,  by  the  use  of  a  suit- 
able pessary. 

When  there  is  considerable  turgidity  of  the  cervix,  from  congestion 
or  active  inflammation,  two  or  three  leeches  applied  to  the  cervix  uteri 
may  be  useful. 

Constitutional  treatment,  hygienic,  and  including  the  exhibition  of 
remedies  by  the  stomach  or  skin,  is  often  essential.  In  some  cases  I 
have  been  satisfied  that  the  unhealthy  condition  of  the  uterine  mucous 
membrane,  leading  to  the  casting  of  shreds  and  membranes,  was  due 
to  syphilitic  disease.  Inquiry  in  this  direction,  by  examining  the  skin 
and  the  state  of  the  mucous  membranes  elsewhere,  as  well  as  by  weigh- 
ing the  history  of  the  patient,  is  important.  A  succession  of  early  abor- 
tions or  dead  children  aifords  highly  presumptive  evidence. 

The  severe  suflering  attending  the  dysmenorrhoeal  paroxysms  may 
be  mitigated  by  opium,  Hoffmann's  anodyne,  chloroform,  chloral,  In- 
dian hemp,  or  other  sedatives.  The  liquor  ammonise  acetatis  is  valu- 
able by  itself,  and  is  the  best  menstruum  for  opium.  Trousseau  recom- 
mended turpentine,  in  twenty-drop  doses,  continued  for  three  months, 
and  the  prolonged  use  of  warm  baths.  C.  Braun  prescribed  small  doses 
of  arsenic,  to  allay  the  attendant  painful  excitement. 

Tonics,  as  iron,  quinine,  strychnine,  arsenic,  and  the  mineral  acids, 
are  almost  always  serviceable,  as  adjuvants  to  local  treatment. 

The  bowels  require  special  care,  as  accumulation  in  the  rectum  is  a 
serious  aggravation  of  all  uterine  affections. 

Prognosis. — But  with  all  possible  care  we  must  be  prepared  to  find 
these  cases  rebellious  to  treatment  for  a  long  time;  sterility  may  be  re- 
garded as  a  consequence ;  for  when  pregnancy  occurs,  and  is  carried  on 
for  some  months,  the  disease  may  be  considered  to  be  cured. 


234  CLIMACTEEIC. 


CHAPTER  XXIII. 

THE  MENSTEUAL  IRREGULARITIES  OF  THE   CLi:SIACTERIC 

EPOCH. 

In  connection  with  the  deviations  from  healthy  menstruation,  it  is 
convenient  to  trace  the  history  of  menstruation  at  the  climacteric  epoch. 
This  epoch  is  sometimes  called  the  "  menopause/'  to  indicate  the  ces- 
sation of  the  function  of  menstruation.  There  is  no  fixed  uniform 
period  for  this  event.  Some  women  cease  to  menstruate  at  forty ;  others 
go  on  till  fifty  or  even  later.  In  some  the  transition  is,  if  not  abrupt, 
at  any  rate  well  marked ;  in  others  the  transition  is  protracted,  inter- 
rupted by  occasional  suspensions,  or  the  missing  of  a  period  or  two. 
The  flow  appears  irregularly,  both  as  to  periodicity  and  quantity. 
This  uncertainty  has  earned  for  the  climacteric  age  the  expressive  term 
of  "the  dodging  time  of  life."  Often  it  is  called  "the  change;"  and 
a  great  deal  is  implied  in  these  expressions.  The  transition-period, 
from  active  ovario-uterine  life  to  the  stage  of  sexual  decrepitude  or 
degeneration,  is  seldom  effected  without  some  disturbance;  and  in  many 
cases  the  local  and  constitutional  disorders  that  attend  it  are  numerous 
and  severe. 

Physicians  do,  indeed,  talk  of  the  climacteric  in  man ;  but  the  analogy 
is  more  fanciful  than  real.  In  the  male  sex  there  is  no  epochal  limita- 
tion of  sexual  life.  There  is  nothing  to  compare  Math  the  almost  sudden 
decay  of  the  organs  of  reproduction  which  marks  the  middle  age  of 
woman.  Whilst  these  organs  are  in  vigor,  the  whole  economy  of  woman 
is  subject  to  them.  Ovulation  and  menstruation,  gestation  and  lacta- 
tion by  turns  absorb  and  govern  almost  all  the  energies  of  her  system. 
The  loss  of  these  functions  entails  a  complete  revolution.  And  before 
the  new  regime  ib  established,  an  interregnum  of  trouble  has  commonly 
to  be  passed  through. 

For  thirty-five  years  or  more,  the  pelvic  organs  have  been  the  seat 
of  active  periodical  congestions,  and  determinations  of  nerve-force. 
When  ovulation  ceases,  this  nerve-force  and  local  activity  of  the  circu- 
lation are  suddenly  called  upon  to  find  other  outlets.  The  transition 
frequently  entails  symptoms  that  partake  of  a  pathological  character. 
These  symptoms  are  chiefly  referred  to  the  circulation,  to  digestion,  and 
to  the  nervous  system.  Menstruation,  instead  of  ceasing  gradually, 
not  seldom  assumes  the  form  of  hemorrhages,  more  or  less  periodical. 
These  are  sometimes  the  result  of  abortions. 

The  last  effort  of  menstrual  life  is  to  propagate.  The  ovaries  retain 
their  function  of  maturing  ova  perhaps  a  little  longer  than  the  uterus 
retains  its  capacity  for  gestation.  As  in  the  outset  of  menstruation  so 
in  the  cessation,  the  uterus  may  be  found  unfit :  in  the  first  case  it  is 
immature;  in  the  second  there  is  commencing  atrophy.  Generally, 
however,  atrophy  of  the  uterus  follows  that  of  the  ovaries. 


PSEUDOCYESIS.  235 

When  hemorrhages  do  not  occur,  or  are  not  substituted  by  vicarious 
discharges,  as  hsemorrhoids,  epistaxis,  or  leucorrhoea,  severe  headaches, 
and  cerebral  congestions  are  liable  to  take  place.  Vertigo,  epilepsy, 
apoplexy  are  more  likely  to  happen.  The  headache  is  peculiar ;  it  is 
chiefly  occipital,  involving  the  nucha  and  spinal  cord ;  and  invokes 
distressing  mental  phenomena.  Minor,  moral,  emotional,  and  intellec- 
tual aberrations  arise.  A  desponding,  gloomy  state,  verging  upon 
hypochondriasis,  is  not  uncommon.  These  are  often  controlled  by  a 
well-regulated  will ;  but  sometimes  they  break  out.  Fretfulness,  irri- 
tability, forgetfulness,  indecision,  are  the  earlier  signs.  There  is  nothing 
so  frequently  complained  of  as  the  want  of  power  of  attention,  and 
consequently  of  loss  of  memory.  The  nervous  disorders  which  so 
often  attend  dysmenorrhoea  and  amenorrhoea,  are  reproduced  at  the 
climacteric  age  with  exaggerated  force.  The  subject  of  them  is  gener- 
ally perfectly  aware  of  her  condition ;  she  feels  acutely  the  distress  her 
waywardness  occasions  to  others ;  and  when  she  is  unable  to  control  it, 
she  will  seek  to  hide  it  in  seclusion  until  it  has  passed  away.  This  is 
often  the  explanation  of  conduct  which,  to  the  unobservant,  appears 
motiveless  or  wilful.  This  power  of  comparison,  of  judgment  is,  as 
Conolly  insists,  that  Avhich  distinguishes  this  condition  from  insanity. 
It  is  a  shallow  saying  that  women  can  give  no  reason  for  what  they  do. 
They  justly  claim  the  privilege  of  weakness  by  declining  to  give  one. 
They  rather  incur  the  reproach  of  being  illogical  or  unreasonable,  than 
wound  their  sense  of  delicacy.  Woman's  decision,  then,  is  to  be  re- 
spected, not  questioned. 

Disorder  of  the  Alimentary  Function  is  one  of  the  most  common 
attendants  upon  the  menopause.  The  habit  of  constipation  has,  per- 
haps, already  been  acquired.  It  becomes  aggravated.  It  would  seem 
that  there  is  a  metastasis  of  nerve-force  to  the  intestines.  They  become 
the  seat  of  severe  spasms.  This  is  due  in  some  cases  to  loss  of  tension 
of  the  abdominal  walls,  the  result  of  pregnancy ;  to  loss  of  tonicity 
from  defective  nutrition  attendant  upon  invalidism  and  want  of  exercise; 
to  obstruction  to  the  action  of  the  bowels  from  pressure  on  the  rectum, 
as  from  retroversion  or  prolapsus  of  the  uterus.  From  these  and  other 
causes,  especially  from  the  tendency  to  adiposity,  the  intestinal  canal, 
wanting  its  normal  contractile  property,  becomes  liable  to  distension 
from  flatulence  and  the  accumulation  of  fecal  matters.  Hence  irrita- 
tion, exciting  spasm,  and  other  irregular  actions  of  the  intestinal  mus- 
cular walls.  The  distress  arising  from  this  source  is  often  very  great ; 
and  in  many  cases  where  the  nervous  centres  are  involved  in  the 
climacteric  confusion,  the  sensations  arising  in  the  belly  are  misinter- 
preted, and  are  the  immediate  occasion  of  mental  phenomena  verging 
upon,  and  not  seldom  passing  into  insane  delusions.  One  of  the  most 
remarkable  yet  familiar  illustrations  of  this  condition,  is  the  conviction 
entertained  by  the  sufferer  that  her  abdominal  symptoms  are  due  to 
pregnancy.  In  some  cases  there  is  enough  evidence,  'prima  facie,  to 
impose  upon  others,  even  upon  the  medical  attendant.  This  state  is 
known  as  "Fake  or  Spicrious  Pregnancy"  a  term  which  has  been 
Hellenized  by  Mason  Good  into  "  Pseudocyesis."  It  is  sufficiently 
marked  to  merit  special  attention.     Although  arising  chiefly  at  the 


236  CLIMACTERIC. 

climacteric  period,  there  is  hardly  any  limit  to  the  age  at  which  these 
symptoms  and  the  subjective  belief  in  pregnancy  may  occur.  Thus,  I 
have  seen  several  examples  of  women  long  past  sixty,  whom  it  was 
difficult  or  impossible  to  convince  that  they  were  not  pregnant.  Some 
of  these  were  married,  some  were  single.  In  the  latter  case  there  had 
been  a  clandestine  intercourse.  The  mental  perturbation  consequent 
upon  the  sense  of  error,  and  the  dread  of  exposure,  rendered  more  vivid 
the  perception  of  the  local  phenomena,  and  completely  overthrew  the 
mental  faculty  by  which  they  were  judged.  We  easily  believe  what 
we  wish  or  fear  to  be  true.  So  strong  is  the  delusion  in  some  cases, 
that  no  amount  of  reasoning  or  authoritative  decision  will  dispel  it.  I 
have  dealt  with  them  in  this  way.  I  have  got  the  patient  to  fix  the 
date  of  presumed  conception ;  the  ordinary  term  at  which  gestation 
would  be  completed  is  thus  determined ;  and  I  have  told  her  to  come 
again  for  examination  at  a  period  of  one  or  two  mouths  after  the  expi- 
ration of  that  term.  Then,  the  appointed  time  having  gone  by  without 
fruit,  the  dreaded  phantom  has  sometimes  been  exorcised.  Even  then, 
perhaps,  not  without  reluctance ;  for  in  spite  of  shame,  of  self-reproach, 
of  the  fear  of  ridicule  and  loss  of  position,  the  dear  delusion  has  been 
hugged  as  a  proof  of  sexual  capacity. 

Thus,  still  in  some  cases  the  delusion  is  cherished  in  spite  of  time,  and 
of  every  argument.  In  these  cases  the  narrow  boundary-line  between  san- 
ity and  insanity  has  been  passed.  Analysis  of  the  mental  condition  will 
commonly  reveal  other  evidence  of  aberration  from  the  healthy  standard. 

Dr.  Crichton  Browne  relates^  a  remarkable  case  in  illustration  of  the 
influence  which  the  mind  can  exert  over  the  uterus  and  ovaries.  A 
woman  long  past  the  climacteric,  whose  last  child  was  fifteen  years  old, 
was  admitted  into  the  West  Riding  Asylum,  declaring  she  was  two 
months  pregnant.  To  this  assertion  she  held  firm ;  and  at  the  end  of  seven 
months  informed  the  attendants  that  she  was  in  labor.  She  persisted 
resolutely  during  four  days  in  going  through  the  performance.  At 
last  when  exhausted,  as  one  who  had  gone  through  a  protracted  labor, 
the  catamenia,  which  had  been  suspended  for  years,  appeared.  In 
many  other  cases  where  insanity  could  not  be  said  to  exist,  the  delusion 
has  been  carried  to  the  extent  of  imitating  or  pretending  labor. 

An  analogous  form  of  pseudocyesis  occurs  in  young  women  who 
have  secretly  incurred  the  risk  of  pregnancy.  Sexual  and  emotional 
excitement,  and  fear  of  consequences,  have  been  attended  by  suppres- 
sion of  menstruation,  enlargement  of  the  abdomen,  disorder  of  digestion 
involving  nausea  and  flatulence,  swelling  and  pain  in  the  breasts. 
Imagination  strengthened  by  fear  does  the  rest.  And  occasionally  the 
conviction  of  pregnancy  persists,  although  the  menstrual  function  is 
regularly  performed. 

Again,  a  woman  marries  within  the  age  when  pregnancy  is  to  be 
expected.  A  similar  train  of  symptoms  quickly  follows.  The  strong- 
est evidence  on  the  other  side  is  unwillingly  received.  The  regular 
return  of  the  catamenia,  the  stationary  size  of  the  abdomen,  the  absence 
of  many  subjective  signs  of  pregnancy,  the  assurance  of  tlie  physician 

1  Brit.  Med.  Journal,  1871. 


PSEUDOCYESIS.  237 

that  the  decisive  objective  signs  also  are  wanting,  are  all  held  of  little 
account.  Here  imagination  is  strengthened  by  hope.  The  doubting 
physician  is  himself  doubted  ;  and  he  must  often  be  content  to  appeal 
to  time,  the  great  solver  of  mysteries. 

The  phenomena  of  pseudocyesis,  however,  most  commonly  occur  at 
the  climacteric  epoch.  And  they  are  often  very  puzzling.  Many 
things  concur  to  put  on  the  semblance  of  pregnancy.  First,  there  is 
the  probability  of  pregnancy.  The  social  condition,  the  history,  an 
existing  family,  a  hitherto  normal  ovario-uterine  life,  the  age  not  yet 
beyond  the  liability,  all  concur  to  strengthen  the  patient's  belief. 

The  irregularity  or  suspension  of  menstruation,  the  contemporane- 
ous enlargement  of  the  abdomen  and  breasts,  all  collected,  make  up 
an  imposing  aggregate  of  symptoms,  easily  accepted  as  decisive  proof 
of  that  which  is  hoped  or  dreaded.  To  this  array  of  symptoms,  slight 
nausea  and  various  nervous  phenomena  are  frequently  added.  There 
is  much  that  is  real  to  lend  color  to  the  belief  in  pregnancy.  Imagi- 
nation does  the  rest ;  it  supplies  the  missing  links  in  the  chain  of  evi- 
dence, and  binds  all  signs,  real  and  imaginary,  together  into  one  whole, 
which  is  confidently  affirmed  to  be  beyond  the  possibility  of  dispute. 
So  vivid  indeed  is  the  emotional  and  mental  force,  that  it  creates  the 
symptoms  which  are  wanting.  The  woman  who  has  been  pregnant 
before,  calls  upon  her  memory  ;  and  so  keen  is  the  edge  set  upon  per- 
ception by  fancy,  that  feelings  counterfeiting  those  she  really  experi- 
enced in  earlier  years  arise  as  it  were  at  her  bidding.  And  by  a 
similar  process  the  woman  who  has  never  been  pregnant,  conjures  up 
into  seeming  existence  the  signs  which  are  suggested  to  her  eager 
mind  by  hearsay  or  reading. 

It  will  often  appear  cruel  to  break  down  the  fond  delusion,  by  ex- 
plaining these  ambiguous  phenomena  by  another  theory.  But  it  must 
be  done.  About  the  age  of  fifty  there  is,  as  Gooch  said,  a  torpid 
state  of  the  uterus,  with  a  flatulent  state  of  the  intestines.  The  omentum 
and  parietes  of  the  abdomen  often  grow  very  fat,  forming  what 
Baillie  called  "  a  double  chin  in  the  belly."  Wind  and  fat  combine 
to  form  the  tumor  which  simulates  the  gravid  uterus.  Air  moving 
about  in  the  bowels  gives  the  sensation  which  is  taken  for  the  move- 
ments of  the  child.     The  enlargement  of  the  breasts  is  also  due  to  fat. 

The  diagnosis  ceases  to  be  puzzling  when  we  carry  out  the  proper 
physical  exploration,  that  is,  when  we  substitute  scientific  objective 
inquiry  for  the  patient's  description  of  her  subjective  sensations. 

Obesity  is  rarely  limited  to  the  abdomen  and  breasts ;  it  is  seen  in 
the  limbs  and  face  also.  And  it  is  an  aphorism  generally  true,  that 
when  a  woman  is  getting  fat  she  is  not  pregnant.  Although  the 
breasts  are  large,  they  want  the  characteristic  changes  of  pregnancy. 
The  abdominal  enlargement  is  felt  to  be  doughy,  yielding  before  firm 
pressure,  nowhere  giving  the  sensation  of  a  defined  firm  globular 
tumor,  and  consequently  not  giving  the  peculiar  feeling  of  a  wavy  or 
living  impulse  under  the  hand,  which  marks  the  peristaltic  movement 
of  the  uterine  wall,  or  the  movements  of  the  foetus.  Percuss,  and 
where  the  pregnant  uterus  ought  to  be,  you  hear  nothing  but  empty 
resonance.     Auscultate,  and  you  hear  the  rolling  of  confined  air,  bor- 


238  CLIMACTERIC. 

borygmi,  instead  of  the  foetal  heart.  Give  chloroform,  as  Simpson 
recommended,  and  the  "phantom-tumor"  disappears;  the  relaxed  ab- 
dominal walls  allow  the  hands  to  sink  freely  down  upon  the  spine  and 
into  the  pelvis.  There  is  nothing  solid.  All  that  is  not  fat  has 
vanished  into  thin  air.  Examine  by  the  vagina,  the  finger  touches  a 
hard  os  uteri,  probably  low  down,  and  near  the  centre  of  the  pelvis ; 
not,  as  in  pregnancy,  soft,  and  directed  backwards.  There  is  no  large 
solid  mass  in  front  of  the  cervix,  but  a  small  uterus,  freely  movable, 
which,  under  chloroform,  and  sometimes  without,  may  be  defined  be- 
tween the  finger  in  the  vagina,  and  the  hand  pressed  in  above  the 
symphysis. 

Treatment. — Although  we  may  have  proved  the  patient  to  be  in 
error  as  to  the  existence  of  pregnancy,  we  must  not  hastily  conclude 
that  she  requires  no  care.  Her  distress  is  often  real.  The  nervous 
symptoms  forming  an  element  in  the  general  climacteric  disorder  will 
be  discussed  in  connection  with  this  subject.  I  will  only  stop  here  to 
say  that  in  many  cases,  a  well-adapted  abdominal  belt  will  give  great 
relief,  by  supporting  the  distended  bowels,  and  the  omentum  and  ab- 
domen weighted  with  fat.  So  much,  however,  depends  upon  tlie  belt 
being  well  made  that  I  think  it  not  out  of  place  to  observe  that,  to 
design  and  construct  abdominal  belts  and  other  mechanical  supports, 
requires  a  special  skill,  which  every  instrument-maker  cannot  be  ex- 
pected to  possess. 

After  the  menopause,  uterine  diseases,  especially  of  an  inflammatory 
kind,  are  more  rare,  and  are  less  active.  The  general  character  is 
rather  that  of  passive  congestion  and  catarrh. 

The  menstrual  flow  must  also  be  regarded  in  the  light  of  a  safety- 
valve,  whose  function  is  to  restore  the  equilibrium  of  the  circulation. 
The  uterine  evacuation  takes  ofP  the  turgescence  of  the  utero-ovarian 
system  of  vessels.  If  this  be  not  done  there  will  probably  be  deter- 
minations of  blood,  local  hsemostases,  where  there  is  no  provision  for 
throwing  off  the  excess  with  safety.  It  is  only  mucous  membranes 
having  a  convenient  communication  M'ith  the  external  surface,  which 
can  discharge  blood  with  safety ;  and  the  uterine  mucous  membrane  is 
pre-eminently  fitted  for  this  purpose.  By  this  evacuation  vascular 
tension  is  relieved,  and  a  great  source  of  nervous  irritation  is  removed. 

In  conjunction  or  not  with  the  phenomena  of  pseuclocyesis,  other 
disorders  of  the  chylopoietic  organs  are  frequent.  That  the  menstrual 
flow  is  an  excretion  performing  to  some  extent  a  cleansing  or  depurat- 
ing oflfi.ce,  can  hardly  be  doubted.  The  manifest  relief  obtained  from 
distressing  symptoms  on  the  appearance  of  the  flow,  so  often  felt,  is 
evidence  of  this.  When  this  excretion  is  suppressed,  it  is  natural  to 
infer  that  the  system  will  feel  the  want  of  an  accustomed  depuratory 
channel.  The  liver,  the  kidneys,  the  skin  will  have  more  to  do ;  and 
the  consequent  defective  excretion  is  aggravated  by  want  of  exercise. 

The  difficult  or  imperfect  action  of  the  liver  and  kidneys  is  pretty 
sure  to  entail  local  stases  in  the  circulation,  and  consequent  disposition 
to  loading  of  the  heart  and  great  vessels.  Hence  there  is  a  disposition 
to  metrorrhagij^.     This  is  sometimes  so  profuse  as  to  induce  a  marked 


NERVOUS     PHENOMENA.  239 

degree  of  ansemia.  The  hemorrhage  may  be  alternated  with  serious 
offensive  discharge,  and  the  suspicion  of  cancer  not  unnaturally  arises. 
The  sallow  skin  and  offensive  discharge  may  be  simply  due  to  degra- 
dation of  the  blood  and  decomposition  of  matters  retained  in  the 
vagina. 

In  a  considerable  number  of  cases  a  copious  flooding  seems  to  be,  if 
not  salutary,  at  any  rate  not  injurious.  I  have  seen  cases  of  aged 
women,  that  is,  sixty  and  even  seventy  years  old,  in  which  sudden 
profuse  vaginal  hemorrhage  occurred  without  a  trace  of  disease,  recov- 
ery following.  These  cases  seem  strictly  analogous  to  those  of  senile 
epistaxis,  which  call  for  plugging  of  the  nostrils. 

But  in  too  many  cases,  disease  of  a  serious  character  is  the  cause. 
Amongst  these,  unhappily,  cancer  is  the  most  common.  Fibroid 
tumors  and  polypi  may  be  found. 

Hemorrhages  at  this  period  of  life  are,  however,  always  the  subject 
of  just  anxiety.  It  is  eminently  desirable  to  analyze  carefully  the 
various  conditions  associated  with  these  symptoms.  In  many  cases 
there  is  no  discoverable  morbid  condition  of  the  uterus.  The  cause 
lies  in  remote  organs,  or  in  the  state  of  the  organs  of  circulation,  or  of 
the  blood  ;  as  in  the  cases  just  referred  to.  An  outburst  of  hemor- 
rhage, under  these  circumstances,  is  sometimes  beneficial.  If  modern 
medicine  had  not  too  absolutely  condemned  venesection  we  should  take 
a  hint  from  this  clinical  fact,  and  imitate  the  practice  of  nature. 

True  eclamptic  convulsions  followed  by  a  stage  of  semi-coma  and 
delirium,  sometimes  occur.  There  may  be  only  one  attack  ;  but  gen- 
erally there  is  a  tendency  to  recurrence  at  more  or  less  regular  inter- 
vals. The  immediate  exciting  cause  is  in  some  cases  the  habit  of  peri- 
odicity, stimulated  or  not  by  remains  of  ovarian  activity.  There  seems 
to  be  a  gradual  accumulation  of  blood  and  nerve-force,  which,  when  a 
certain  tension  is  reached,  breaks  out  in  the  way  described.  If  it  should 
happen  that  a  discharge  of  blood  takes  place,  the  nervous  phenomena 
are  generally  mitigated. 

These  attacks  are  commonly  followed  by  periods  more  or  less  pro- 
longed, during  which  the  cerebral  functions  are  impaired.  Perception 
rarely  suffers  so  much  as  other  facalties.  Attention  is  commonly  im- 
paired. The  patient  finds  it  difficult  to  follow  a  conversation,  or  to 
keep  up  a  continuous  train  of  thought.  Aphasia  is  a  frequent  phe- 
nomenon. Articulation  may  be  impaired ;  but  the  main  difficulty  con- 
sists in  finding  the  word  that  is  wanted.  The  patient  is  quite  conscious 
that  she  is  using  the  wrong  word,  and  tries  by  signs,  or  relies  upon  the 
knowledge  or  intuition  of  those  whom  she  is  addressing,  to  correct  and 
fill  up  what  she  wants  to  express.  The  mind  is  essentially  right;  but 
the  organ  of  expression  is  at  fault. 

The  patient  is  at  first  stunned  by  the  shock  of  the  attack.  Recovery 
is  gradual,  sometimes  slow.  Headache  is  a  common  symptom ;  pains 
in  different  parts  of  the  body  are  felt :  there  is  often  a  marked  disposi- 
tion to  sleep.  The  want  of  rest  is  attested  in  many  ways.  She  is  easily 
exhausted  by  exertion,  bodily  or  mental. 

In  some  cases  the  phenomena  may  be  described  as  epileptoid  only. 
There  is  not  complete  loss  of  consciousness,  but  a  degree  of  vertigo. 


240  CLIMACTERIC. 

The  face  becomes  pale,  cool ;  and  irregular  movements  of  the  limbs  are 
enacted. 

In  another  class  the  symptoms  are  syncopal  in  character.  For  some 
time  there  is  almost  complete  loss  of  consciousness.  At  least  in  many- 
cases  there  is  no  subsequent  recollection  of  what  occurred  during  the 
attack; — nothing  but  a  confused  notion  of  the  circumstances  attend- 
ing the  beginning  and  the  recovery  from  it.  The  patient  may  fall 
down,  suffer  injury,  and  yet  be  unaware  of  what  has  happened. 

Associated  with  this  kind  of  attack,  and  no  doubt  to  a  great  extent 
accounting  for  it,  there  is  often  a  weak  condition  of  the  heart.  The 
organ  is  badly  nourished,  loaded  with  fat  deposit,  if  not  also  degenera- 
ted in  fibre ;  it  is  dilated,  and  incapable  of  acting  efficiently  under  the 
call  of  sudden  excitement  or  exertion. 

All  these  nervous  abnormalities,  and  the  disposition  to  hemorrhage, 
are  unfortunately  liable  to  be  seriously  aggravated  by  the  frequent  re- 
sort to  alcoholic  stimulants.  Under  the  immediate  depression  induced 
by  nervous  exhaustion  or  flooding,  relief  is  sought  from  wine  or  brandy ; 
necessarily  so  perhaps  in  many  cases.  But  the  habit  of  flying  to  this 
ready  and  tempting  aid  is  easily  acquired  ;  and  then,  the  ills  of  alco- 
holism being  added  to  those  already  existing,  a  vicious  circle  of  morbid 
reactions  is  set  going,  and  gathers  strength  with  every  revolution. 

I  have  already  observed  that  apoplexy  and  eclampsia  are  more  likely 
to  happen  at  the  climacteric  period.  But  the  cases  are  more  frequent 
in  which  these  diseases  are  simulated.  Many  women  complain  of  a 
partial  hemiplegia,  chiefly  of  sensation.  This  is  not  preceded  by  coma 
or  convulsion ;  the  mind  is  unaffected ;  the  patient  can  walk  nearly  as 
well  as  usual,  and  without  any  perceptible  dragging  of  one  leg.  She 
describes  various  subjective  symptoms,  as  numbness,  coldness,  tingling 
in  the  arm  and  leg.  No  difference  in  temperature  of  the  two  sides  can 
be  detected. 

With  or  without  these  apparent  paralytic  phenomena,  there  are  fre- 
quent alternations  of  flushes  in  the  face,  and  chills.  These  are  apt  to  come 
on  on  the  slightest  fatigue  or  emotion,  and  constitute  one  of  the  most 
frequent  conditions  which  harass  women  of  a  certain  age.  The  flushes 
are  often  visible  to  others ;  the  face  becomes  red,  or  even  empurpled, 
and  there  is  a  feeling  of  giddiness  or  vertigo.  These  are  no  doubt  the 
result  of  that  extreme  tendency  to  sudden  aberrations  of  nerve-force 
and  of  blood-supply,  so  characteristic  of  "  the  change."  It  seems  as  if 
the  equable  distribution  of  health  were  replaced  by  irregular  supplies 
sent  in  excess  to  particular  organs,  or  vascular  and  nervous  systems. 

The  treatment  of  disorders  of  the  menopause. 

The  principle  of  dealing  with  these,  flows  from  the  observation  of 
their  natural  history.  Our  care  must  be  directed  to  counteract  the 
sluggishness  of  the  liver,  and  the  imperfect  action  of  the  other  digestive 
organs ;  to  regulate  the  circulation  of  the  secretions ;  and  to  guide 
aright  as  far  as  possible  the  nervous  functions. 

In  the  disorders  attended  by  plethora,  florid  complexion,  tendency 
to  embonpoint,  and  convulsions,  abstraction  of  eight  or  ten  ounces  of 
blood  from  the  arm  will  often  be  of  signal  service.  If  this  be  consid- 
ered too  great  an  outrage  upon  the  exsanguineous  therapeutics  of  the 


TREATMENT.  241 

present  day,  we  may  compromise  the  «iatter  by  applying  four  or  six 
leeches  to  each  temple  or  behind  the  ears.  I  have  frequently  seen  the 
greatest  benefit  from  cupping,  taking  by  this  means  eight  or  ten  ouncas 
of  blood  from  the  nucha  or  between  the  shoulders. 

The  loss  of  a  small  quantity  of  blood  will  often  act  in  the  most 
remarkable  manner.  That  I  have  seen  lives  saved  by  this  practice, 
that  conditions  threatening  cerebral  congestion  or  apoplexy  have  been 
averted  by  it,  I  have  no  manner  of  doubt.  I  have  seen  women  con- 
ducted over  the  greatest  perils  of  the  critical  age  by  occasional  leeching 
and  cupping,  combined  with  judicious  medicinal  and  hygienic  manage- 
ment. These  abstractions  of  blood,  small  as  they  are,  produce  good 
results  out  of  proportion  to  their  quantity.  They  act  as  derivatives  as 
well  as  evacuants.  By  taking  off  the  tension  of  the  vascular  system, 
and  diverting  the  current  of  the  blood  to  the  surface,  they  equalize  the 
circulation,  and  free  the  central  organs,  which  are  gorged  with  blood 
approaching  to  stagnation.  They  act,  in  short,  as  the  most  direct  and 
eifective  substitute  for  the  wanting  menstrual  bleeding. 

The  regulation  of  the  secretions  is  best  effected  by  occasional  resort 
to  alterative  remedies,  as  blue  pill  with  colocynth  or  aloes  and  bella- 
donna ;  podophyllin ;  salines,  of  which  the  best  is  acetate  of  ammonia  ; 
a  little  colchicum  is  often  of  signal  service.  The  habitual  use  of  Pullna 
or  Friedrichshall  waters  is  often  of  great  service.  Patients  have  ex- 
pressed themselves  as  highly  pleased  with  the  use  of  the  galvanic  belts 
in  exciting  the  action  of  the  bowels,  and  in  enabling  them  to  dispense 
with  purgative  medicines.  The  skin  should  be  kept  in  working  order 
by  exercise  and  baths,  and  often  the  addition  of  Vichy  salts  to  the  baths 
will  be  useful.  The  nervous  centres  are  calmed  and  regulated  by  occa- 
sional sedatives,  as  the  acetate  of  ammonia  with  Battley's  solution,  or 
chloral.  But  the  most  valuable  remedy  is  the  bromide  of  potassium. 
This  may  be  given  in  ten-grain  doses  or  larger,  two  or  three  times  a 
day  for  a  considerable  time,  with  occasional  intermission,  taking  care 
to  resume  it  whenever  the  nervous  symptoms  threaten  to  return. 

To  equalize  the  action  of  the  heart  and  counteract  local  stases,  salines 
are  again  of  value,  and  their  good  effect  is  often  enhanced  by  digitalis. 

Where  there  is  deficient  tone,  as  is  often  the  case,  quinine  and  strych- 
nine with  mineral  acids  are  indicated.  Amongst  other  useful  proper- 
ties, these  agents  possess  that  of  improving  muscular  tone,  and  thus  of 
counteracting  the  sluggish  condition  of  the  intestinal  canal. 

The  establishment  of  an  issue  in  the  back  of  the  neck,  or  on  the  arm, 
operates  as  a  valuable  derivative.  I  have  known  women  kept  free  from 
nervous  seizures  so  long  as  an  issue  was  open,  and  be  again  subject  to 
them  when  the  issue  was  healed. 

Attention  to  the  diet  is  of  the  utmost  importance.  Many  things 
which  have  come  to  be  looked  upon  as  necessaries,  but  which  are  really 
luxuries,  must  be  given  up,  or  taken  with  the  strictest  moderation. 
The  food  should  consist  of  fish,  meat,  poultry,  game,  carefully  but 
plainly  cooked,  bread,  vegetables,  and  fruit.  The  allowance  of  meat 
should  be  restricted  to  one  meal  a  day.  Spirits  generally  should  be 
avoided,  port  should  be  shunned  absolutely,  and  sherry  taken  rarely ; 
sparkling  wines  mixed  with  soda  or  seltzer,  claret,  carlowitz,  or  hocks, 

16 


242  MENSTRUATION. 

may  be  alloAved  to  the  extent  of  two  or  three  glasses  daily.  Beer,  as  a 
rule,  is  unsuitable  for  climacteric  women. 

I/ithiasis  is  especially  apt  to  arise  at  this  period,  and  may  give  rise 
to  those  attacks  of  excruciating  agony  characteristic  of  the  irritation  of 
graved  in  the  urinary  track.  These  attacks  must  be  distinguished  from 
the  pain  which  attends  some  forms  of  uterine  disease. 

GalMones  also  are  apt  to  be  troublesome  under  the  same  conditions. 
The  loaded  portal  system,  the  sluggish  liver  perhaps  undergoing  some 
organic  change,  easily  engender  disorder. 

The  gorged  state  of  the  portal  system,  and  the  pressure  upon  the  kid- 
neys, are  shown  in  the  turbid  urine,  loaded  with  lithates  and  phosphates, 
and  occasionally  containing  albumen  and  biliary  matter.  Vomiting 
not  uncommonly  attends  this  condition.  Alkaline  salines  steadily  ad- 
ministered oiFer  the  best  means  of  relief. 

Sometimes  the  troubles  of  the  menopause  subside  gradually  and  en- 
tirely. But  they  rarely  disappear  altogether  in  less  time  than  two  or 
three  years.  The  woman  then  seems  to  take  a  new  lease  of  life.  She 
resumes  her  physical  and  mental  power.  Sometimes,  however,  these 
troubles  persist  and  merge  into  those  w^hich  mark  the  period  of  decrepi- 
tude. 


CHAPTER  XXIV. 

THE  EELATIONS  OF  MEISTRTEUATION  TO  VARIOUS  DISEASES— THE 
INFLUENCES  OF  OVULATION  AND  MENSTRUATION  IN  EVOK- 
ING MORBID  INFLUENCES. 

In  discussing  this  subject  it  would  be  convenient  to  consider,  first, 
the  influence  of  disease  in  other  organs  or  in  the  system  generally, 
upon  the  function  of  menstruation;  and  secondly,  the  influence  of  ovu- 
lation and  menstruation  in  producing  diseased  action  in  other  organs, 
or  in  the  system  at  large.  In  a  considerable  number  of  cases  this 
could  be  done.  But  there  are  other  cases  in  which  the  action  and  reac- 
tion are  so  close,  that  it  is  scarcely  possible  to  get  at  the  first  factor. 
So  we  are  compelled  by  clinical  necessity  to  study  some  cases  from  both 
sides,  that  is,  to  observe  the  reciprocal  influences  of  ovulation,  and  men- 
struation, and  diseased  actions. 

In  some  diseases,  menstruation  is  diminished  or  altogether  arrested. 
This  is  especially  the  case  in  chronic  wasting  diseases  which  induce 
degradation  of  the  blood.  Phthisis  is  a  marked  example  of  this  kind. 
Ovulation,  indeed,  is   not  arrested,  but  the  ordinary   menstrual  dis- 


RELATIONS    OP    MENSTRUATION.  243 

charge  gradually  diminishes,  and  generally  ceases  altogether.  This  is 
partly  due  to  the  waste  of  red  corpuscles ;  partly  to  the  diminished 
force  of  the  circulation;  partly  to  the  morbid  process  causing  deriva- 
tion of  blood  away  from  the  uterus ;  and  partly  from  impaired  nutri- 
tion of  the  ovaries.  Louis  observed  that  cessation  of  the  menses  was 
seldom  delayed  beyond  the  onset  of  the  tubercular  hectic.  Acute  lung 
inflammations  do  not  entail  much  interference,  menstruation  usually 
appearing  notwithstanding.  In  the  great  majority  of  affections  of  the 
spinal  cord,  menstruation  is  not  suspended. 

When  menstruation  makes  its  appearance  in  the  course  of  a  disease, 
especially  in  fevers,  it  has  been  looked  upon  as  critical,  and  as  exer- 
cising a  favorable  influence.  There  is  little  evidence  of  the  truth  of 
this  theory.  Perhaps  the  case  is,  that  when  the  disease  is  going  on 
favorably,  there  is  more  probability  of  menstruation  being  restored. 
At  the  same  time  a  useful  indication  may  sometimes  be  drawn  from  the 
manifest  relief  which  follows  the  appearance  of  the  menstrual  flow  in 
many  morbid  conditions,  to  solicit  or  promote  the  floM^  or  to  establish 
an  equivalent  for  it,  by  a  topical  or  general  bleeding. 

In  exanthematous  fevers,  as  small-pox,  scarlatina,  measles,  or  typhoid, 
sanguineous  discharge  occasionally  takes  place  from  the  vagina. 
Sometimes  this  is  undoubtedly  menstrual.  But  in  most  instances  it  is 
to  be  regarded  in  the  same  light  as  the  epistaxis  which  occurs  under 
similar  circumstances.  These  fevers,  especially  small-pox  and  typhoid, 
induce  a  state  of  blood  favorable  to  extravasation  from  the  mucous 
surface  and  skin.  The  utero-vaginal  tract  is  of  course  likely  to  be  the 
seat  of  this  effusion ;  and  if  menstruation  be  impending,  the  flow  will 
probably  be  profuse.  In  studying  the  etiology  of  pelvic  hsematocele 
we  shall  see  that  under  these  circumstances,  blood  may  flow  back  from 
the  Fallopian  tubes,  and  escape  into  the  peritoneum. 

We  have  another  example  of  hemorrhage  from  the  genital  tract  in 
"  malignant  jaundice,"  or  "acute  yellow  atrophy  of  the  liver."  Here, 
also,  there  is  no  special  tendency  to  metrorrhagia.  The  genital  hemor- 
rhage is  simply  the  result  of  a  general  alteration  in  the  blood  which 
disposes  it  to  exude  from  all  the  mucous  membranes. 

As  this  subject  has  not  attracted  the  attention  it  deserves,  I  am 
happy  to  have  the  opportunity  of  embodying  the  results  of  extensive 
observation  and  inquiry,  kindly  made,  at  my  request,  by  my  colleague, 
Dr.  Clapton.  Phthisis,  he  says,  in  nearly  every  case  stops  menstrua- 
tion; in  the  majority,  abruptly,  but  sometimes  after  gradual  diminu- 
tion. Not  uncommonly  phthisis  appears  to  be  developed  in  conse- 
quence of  emansio  mensium,  but  in  almost  all  these  instances  there  is 
evidence  of  scrofulous  diathesis.  In  Scrofula,  there  is  great  irregularity 
as  to  time,  quantity,  and  character.  As  a  rule  there  is  delay,  deficiency, 
or  suppression.  In  Bronchocele  menstruation  is  generally  scanty  and 
pale.  In  Neuralgia  it,  as  a  rule,  diminishes.  Neuralgia  is  often  asso- 
ciated, either  as  cause  or  effect,  with  dysmenorrhoea.  Malarious  affec- 
tions diminish  the  secretion ;  the  color  is  pale.  Chorea  is  not  common 
after  puberty,  except  in  pregnant  young  women;  but  when  it  does 
occur  it  is  generally  associated  Avith  either  dysmenorrhoea  or  emansio 
mensium.     The  influence  of   Epilepsy  is  uncertain;  menstruation  is 


244  M  E  X  S  T  R  U  A  T  I  O  X. 

generally  regular,  but  if  not,  there  is  a  tendency  to  excessive  or  too 
frequent  flow.  Hysteria  is  sometimes  cause,  sometimes  effect  of 
amenorrhoea;  it  is  usually  associated  with  dysmenorrhoea ;  more  rarely 
with  menorrhagia.  Inflammatory  and  congestive  diseases  of  the  brain 
and  spinal  cord  tend  to  increase  the  menstrual  flow,  the  degenerative 
tend  to  diminish  it;  'paraplegia,  if  from  hypersemia,  increases,  if  from 
anaemia  decreases  the  flow.  3Iania  generally  increases  the  discharge ; 
melancholy  diminishes  it;  dementia  usually  occurs  after  cessation  of 
catamenia;  in  idiocy,  in  the  majority  of  cases,  menstruation  is  regu- 
larly performed,  in  others  there  is  emansio  mensium.  Surgical  inju- 
ries, attended  by  shoch  or  concussion,  generally  check  menstruation  if 
occurring  during  the  flow,  but  tend  to  induce  it,  if  occurring  during  the 
intervals.  Pycemia  at  once  suppresses  the  discharge.  In  secondary 
syphilitic  affections  there  is  no  alteration.  (This  I  would  qualify  by 
observing  that  where  the  uterine  mucous  membrane  is  aflected,  as  it  often 
is,  there  is  a  tendency  to  menorrhagia.)  Purpura  disposes  to  uterine 
hemorrhage.  Typhus  and  enteric  fevers  and  exanthemata  retard,  and 
sometimes  suppress  for  a  long  time  after  the  attack.  In  some  of  the 
worst  cases  there  is  uterine  hemorrhage  at  the  time.  Rheumatism  and 
gout  have  little  apparent  effect,  except  that  in  rheumatic  fever  men- 
struation is  generally  delayed.  After  one  attack  of  acute  rheumatism, 
menstruation  is  usually  suppressed  for  a  month  or  two.  Congestive 
liver  diseases  often  for  a  time  increase,  whilst  the  atrophic  diseases  di- 
minish or  suppress  it.  Chronic  diarrhoea  or  dysentery  tend  to  diminish 
or  suppress.  Of  kidney  diseases,  the  inflammatory  or  congestive  gene- 
rally increase  menstruation,  whilst  the  fatty  and  amyloid  diminish  or 
stop  it.  Diabetes  diminishes,  and  after  a  time  stops  the  secretion,  but 
in  some  cases  there  is  no  change.  Heart  diseases:  distension  of  the 
right  cavities,  and  affections  of  the  mitral  valves  tend  to  increase, 
whilst  aortic  diseases  generally  diminish  or  stop  menstrual  flow.  In 
ephysema  and  asthma  as  a  rule  there  is  no  change ;  if  any,  there  is 
dysmenorrhoea.  In  chronic  bronchitis  and  pneumonia  there  is  no 
change. 

The  above  conclusions  agree  very  closely  with  my  own  observations. 
Some  of  them  will  be  discussed  or  illustrated  hereafter. 

Acne  is  one  of  the  forms  of  skin  affection  induced  or  influenced  by 
disorder  of  menstruation.  At  least  an  eruption  of  this  form  has  been 
noticed  at  every  month  when  menstruation  has  been  suppressed,  and 
has  ceased  when  the  function  was  restored.  The  internal  administra- 
tion of  arsenic  is  often  useful  in  these  cases.  The  acne  pustules  may 
be  touched  with  butter  of  antimony  by  a  camel-hair  pencil,  taking  care 
to  neutralize  the  caustic  immediately  with  a  little  solution  of  bicarbon- 
ate of  soda. 

The  influence  of  ordinary  menstruation  upon  the  breasts  has  been 
already  alluded  to.  Of  the  influence  of  obstructed  menstruation  upon 
morbid  conditions  of  the  breasts  I  have  seen  several  remarkable  illus- 
trations. Some  years  ago  a  single  lady  came  to  me  from  the  country, 
suffering  so  much  from  dysmenorrhoea  that  her  health  was  breaking 
down.  She  had,  besides,  a  suspicious  hard  tumor  m  the  left  breast, 
for  which  she  consulted  the  late   Mr.  C.  H.  Moore,  surgeon  to  the 


RELATIONS    OF    MENSTRUATION.  245 

Middlesex  Hospital.  The  dysmenorrhoea  I  concluded  was  due  to  ex- 
treme narrowing'  of  the  os  uteri.  I  dilated  this  by  incision,  and  almost 
complete  relief  from  dysmenorrhoea  ensued ;  and  whereas  the  tumor  in 
the  breast  had  previously  been  progressing  unfavorably  under  monthly 
exacerbations  of  pain  and  s^A^elling,  it  now  became  quiescent,  and  scarcely 
gave  any  distress.  Several  years  have  now  elapsed,  and  the  tumor  is 
still  dormant.  Mr.  Moore  was  himself  so  struck  witli  the  beneficial 
effect  attending  the  relief  of  the  utero-ovarian  distress,  that  he  read  a 
paper  on  the  case  before  a  meeting  of  the  British  Medical  Association. 
It  is  one  amongst  many  proofs  constantly  observed  in  practice,  of  the 
wisdom,  when  cases  of  complicated  diseases  come  before  us,  of  elimin- 
ating any  one  of  the  complications  that  may  be  within  our  power,  in 
the  assurance  that,  generally,  the  remaining  diseases  wall  be  mitigated, 
and  the  load  borne  by  the  patient  be  so  much  lightened. 

Menstruation  seems  to  induce  a  state  of  hypersesthesia  or  nervous 
erethism,  under  which,  evils  that  in  the  intervals  lie  dormant  or  quies- 
cent are  brought  into  prominence.  Thus  I  have  a  lady  under  my  care 
for  endometritis  folloAving  abortions  induced,  I  have  no  doubt,  by  a 
syphilitic  diathesis,  and  who  has  also  a  stiif  knee  with  chronic  synovitis, 
for  which  she  saw  my  colleague,  Mr.  Le  Gros  Clark.  At  every  period 
pain  came  on  in  the  knee,  and  her  lameness  was  worse ;  and  at  the  same 
time  an  old  syphilitic  eruption  on  the  chest  would  reappear.  In  numer- 
ous instances  I  have  known  intense  facial  neuralgia  occur  at  every 
period. 

The  influences  of  chronic  nervous  disorder  upon  ovulation  and  men- 
struation is  not  often  very  clearly  marked.  But  sudden  strong  emo- 
tions, acting  as  it  were  by  shock,  often  exercise  an  unmistakable  influ- 
ence. In  some  cases,  profuse  flooding  is  produced ;  in  others  the  secretion 
is  checked,  and  even  protracted  amenorrhoea  is  induced. 

Negrier  says,  "  Softening  of  the  brain  does  not  always  suspend  men- 
struation." The  ovaries  receive  their  innervation  from  the  ganglionic 
system.  For  the  like  reason  chronic  affections  of  the  brain  do  not  usu- 
ally interrupt  ovarian  functions.  On  the  other  hand,  ovarian  function 
exerts  great  influence  upon  diseases  of  the  brain,  especially  when  the 
ovaries  are  unusually  developed.  Thus,  ovulation  sensibly  aggravates 
intellectual  disorders,  and  frequently  stamps  them  with  an  hysterical 
character.  Treatment  tending  to  moderate  ovarian  action  would  be 
useful. 

In  tracing  the  history  of  *^  the  menstrual  irregularities  of  the  climac- 
teric period"  in  the  preceding  chapter,  we  have  seen  illustrations  of  the 
relations  of  menstruation  to  various  nervous  phenomena.  I  may  men- 
tion in  this  place,  that  very  similar  nervous  disorders  are  often  mani- 
fested in  connection  with  disordered  menstruation  at  the  onset  of  sexual 
life.  Thus,  vertigo,  syncope,  epilepsy,  neuralgia,  mental  aberrations 
varying  in  degree,  are  not  uncommon.  A  young  lady  came  several 
times  under  my  observation  in  consultation,  at  the  age  of  sixteen  and 
afterwards.  She  never  had  fits  in  infancy  or  childhood.  At  fourteen 
menstruation  began  ;  it  soon  became  arrested  or  irregular,  and  epileptic 
fits  appeared.  The  epochs  were  indicated  by  pelvic  uneasiness  ;  the  fits 
generally  occurred  a  week  after  the  menstrual  effort.     Her  aspect  was 


246  MENSTEUATION. 

heavy,  but  she  was  not  wanting  in  intelligence.  There  was  a  scrofulous 
diathesis.  By  the  application  of  leeches  to  the  inside  of  the  thighs  at 
the  epochs,  and  the  use  of  bromide  of  potassium,  she  greatly  improved, 
and  when  menstruation  was  properly  restored,  she  had  no  more  fits. 

Marotte,^  in  a  special  memoir,  adduces  interesting  illustrations  of  the 
relations  of  epilejisy  with  menstruation.  Leuret  relates  a  case  of 
mania  recurring  at  every  period,  and  subsiding  with  the  ap^iearance 
of  menstruation.  The  following  case  from  N§grier  deserves  special 
attention. 

Epilepsy  under  Ovarian  Irritation  and  Flow  to  Head. 

X ,  aged  twenty-one,  of  general  good  health,  never  menstru- 
ated, felt  for  first  time,  ten  months  ago,  violent  lumbar  colics.  After 
several  of  these  attacks,  she  suddenly  fell  down  seized  with  convul- 
sions, and  loss  of  sight ;  sensibility  and  intelligence  remained ;  could 
not  articulate.  She  afterwards  related  that,  at  the  beginning  of  the 
attack,  the  blood  flew  to  her  throat,  and  she  felt  a  sudden  choking. 
During  the  convulsive  state  the  face  was  at  times  red,  at  times  pale 
and  greenish.  From  this  time,  on  the  11th  or  12th  of  each  month, 
this  girl  was  seized  with  tremblings  and  flushes  in  the  face,  soon  fol- 
lowed by  convulsive  attacks  like  that  described.  The  "  lumbar  colics" 
always  preceded  the  attacks.     She  never  had  vaginal  hemorrhage. 

She  was  virginal ;  only  a  rudimentary  uterus  the  size  of  a  walnut 
could  be  felt.  This  case,  like  the  one  observed  at  St.  George's  Hos- 
pital (see  page  156),  affords  another  proof  that  ovarian  development 
may  exist  with  defective  development  of  the  uterus.  My  observations 
of  epistaxis  with  menstruation  show  that  blood  does  fly  to  the  head. 

The  relations  of  the  sexual  functions  to  the  various  forms  of  insanity, 
form  a  subject  of  the  highest  clinical  interest.  The  occasional  outbreak 
of  insanity  after  childbirth  unequivocally  demonstrates  the  influence  of 
childbirth  upon  the  nervous  system.  Phenomena  scarcely  less  strik- 
ing are  not  seldom  seen  in  connection  with  disorders  in  the  menstrual 
function.  There  is  evidence  to  show  that  disease  of  the  ovaries  is 
occasionally  the  exciting  cause  of  mental  disease.  With  the  view  of 
obtaining  some  precise  information  upon  this  subject,  I  have  asked  for 
the  experience  of  my  former  colleague.  Dr.  Down,  formerly  resident 
physician  at  the  Asylum  for  Idiots,  and  my  old  pupil.  Dr.  Davis, 
superintendent  of  the  Burntwood  Asylum.  Dr.  Down  says  that  idiocy 
tends  to  diminish  the  quantity  of  the  flow.  Menorrhagia  does  some- 
times occur,  but  it  is  veiy  rare.  Great  irregularity  as  to  periodicity 
is  also  noticed.  In  the  great  majority  of  cases  the  commencement  of 
menstrual  life  is  attended  by  no  marked  results.  Occasionally,  how- 
ever, acute  mania,  or  acute  melancholia,  becomes  engrafted  on  the 
idiocy,  and  disappears  on  the  completion  of  the  change. 

Dr.  R.  A.  Davis  says :  "  In  all  the  cases,  whether  puerperal  mania, 
ordinary  mania,  or  melancholia,  during  menstruation,  the  symptoms 
are  mostly  aggravated.     In  the  cases  of  melancholia  and  of  those 

1  Kapports  de  I'Epilepsie  avec  la  Menstruation.     (Revue  Med.  Chir.,  1851.) 


RELATIONS    OF    MENSTRUATION.  247 

having  a  suicidal  disposition,  extra  watching  is  required  lest  they 
should  commit  suicide  during  the  menstrual  periods.  I  find  in  nearly- 
all  cases  on  first  admission,  that  the  menstruation  is  either  very  irregu- 
lar, or  suppressed  for  some  time  beforehand." 

Negrier  relates  the  following  amongst  other  interesting  cases :  X , 

aged  seventeen,  menstruated  at  fourteen,  was  seized  with  hysteriform 
symptoms  coinciding  with  menstrual  derangement.  After  several 
closely  succeeding  convulsive  attacks,  this  girl,  well  brought  up,  and 
very  intelligent,  became  insane,  exhibiting  erotic  delirium,  obscene 
talk  and  acts.  Secluded  in  an  asylum,  under  most  cruel  treatment, 
she  recovered  after  a  year,  married  at  nineteen,  and  had  six  children, 
all  of  which  she  suckled.     She  gave  no  further  sign  of  mental  disorder. 

"  Pregnancy  exerts  a  happy  and  powerful  derivation  in  insanity, 
especially  if  this  state  of  the  encephalon  has  for  cause  a  nervous  dis- 
order of  hysterical  form."  The  condition  being  that  the  ovaries  are 
kept  in  abeyance  during  the  temporary  rule  of  the  uterus. 

This  is  strikingly  shown  in  the  following  case  of  N^grier :  X 

was  hysterical  from  nubility,  was  seized  with  insanity  almost  imme- 
diately after  marriage ;  always  recovered  her  intellect  during  her  nu- 
merous gestations,  and  during  the  first  months  of  suckling.  She  re- 
lapsed into  her  mental  alienation  as  soon  as  the  ovarian  function  mani- 
fested itself. 

Dr.  Crichton  Browne,  medical  director  of  the  West  Riding  Asylum, 
bears  decided  testimony  to  the  inter-reactions  of  the  ovario-uterine  and 
nervous  systems :  "A  condition  of  mental  agitation  may,  he  says,  de- 
range the  menstrual  discharge,  and  ideas  may  modify  the  nutrition  of 
the  sexual  apparatus."  He  gives  a  remarkable  illustration  of  this, 
which  has  been  cited  at  length  under  "  Pseudocyesis."  Under  the  in- 
fluence of  imaginary  labor,  a  discharge  simulating  the  menstrual  was 
brought  on  in  a  woman  long  past  the  menopause.  It  is,  Dr.  Browne 
observes,  in  the  close  and  subtle  relation  between  the  bcain  and  the 
pelvic  viscera,  which  is  so  curiously  exemplified  in  the  case  just  de- 
scribed, that  the  source  of  hysterical  mania  must  be  sought.  The  one 
constant  element  in  all  cases  of  this  disorder,  is  a  disturbance  of  the 
balance  of  action  and  reaction  which  subsists  between  the  nervous 
centres  and  the  reproductive  organs.  In  every  instance  of  it,  the  brain 
and  the  uterus  have  their  functions  constantly  deranged ;  for  whatever 
may  be  true  of  simple  hysteria  as  encountered  in  general  practice,  it 
would  not  hold  good  of  hysterical  mania  as  seen  in  asylums,  that  it  may 
accomplish  its  whole  course  without  the  involvement  of  the  generative 
system.  The  morbid  process  may  originate  in  the  brain  or  in  the 
uterus ;  but  in  either  case  it  spreads  from  the  one  to  the  other,  and 
upsets  that  harmony  and  proportion  of  function  in  which  health  con- 
sists. "As  the  result,"  Dr.  Browne  further  says,  "of  large  experience 
of  hysterical  mania,  I  am  satisfied  that  it  is,  without  exception,  pre- 
ceded or  accompanied  by  some  derangement  of  the  reproductive  system, 
the  existence  of  which  is  most  frequently  indicated  by  alteration  or 
obstruction  of  the  monthly  discharge.  Even  where,  however,  neither 
amenorrhoea,  leucorrhcea,  nor  menorrhagia  can  be  discovered,  other 


248  MENSTRUATlOJSr. 

signs  of  disorder  in  the  functions  of  the  reproductive  organs  can  be 
found,  if  carefully  looked  for." 

I  venture  to  affirm  that  in  the  great  majority  of  cases  of  so-called 
"simple  hysteria"  met  with  in  ordinary  practice,  the  intimate  associa- 
tion between  the  reproductive  organs  and  the  nervous  disorder,  which 
Dr.  Browne  so  constantly  found  in  the  case  of  hysterical  mania,  will 
be  discovered  if  looked  for  with  intelligence. 

The  rapid,  almost  sudden  bursting  into  womanhood,  attests  the  influ- 
ence of  the  complete  evolution  of  the  sexual  organs.  The  nervous  system 
especially,  is  profoundly  affected ;  sentiments,  disposition,  pursuits  are 
changed.  Menstruation,  a  function  compounded  of  ovulation,  an  effort 
at  reproduction,  and  of  a  periodical  discharge  of  blood,  exercises  a  two- 
fold influence  upon  the  general  system.  The  relations  of  the  discharge 
have  chiefly  attracted  attention,  whilst  those  of  the  higher  antecedent 
function  of  ovulation  have  been  comparatively  overlooked.  Although 
the  menstrual  discharge  may,  by  its  variations  in  character,  frequently 
give  note  of  what  is  passing  in  the  ovaries,  we  must  be  careful  not  to 
conclude  that  this  is  always  so.  It  would,  indeed,  be  convenient  for 
the  clinical  observer,  if  he  could  depend  upon  the  menstrual  discharge 
as  a  constant  index  of  the  state  of  the  ovary.  In  studying  the  rela- 
tions of  menstruation,  we  are  mostly  compelled  to  take  the  function  as 
a  whole,  including  the  discharge  and  the  ovulation ;  for  v/e  can  rarely 
assign  the  effects  we  witness  to  the  one  factor,  independently  of  the 
other. 

Whenever  an  organ  is  the  seat  of  a  secretion,  it  is  endowed  with  a 
particular  mode  of  vitality  in  relation  with  the  function  it  has  to  fulfil. 
When  this  secretion  is  periodical,  there  are  alternations  of  action  and  of 
repose,  which  preserve  the  equilibrium  of  action  of  the  different  organs. 
When  the  activity  is  spent  upon  one  point,  there  is  derivation  at  the 
expense  of  other  parts,  and  every  exaggeration  of  this  activity  is  a  dis- 
turbance of  the  general  equilibrium ;  in  the  same  way  as  the  sudden 
cessation  of  the  functions  recalls  the  activity  to  another  organ,  which 
becomes  the  seat  of  a  movement  of  fluxion  appropriate  to  its  structure. 
It  is  thus  a  dynamic  metastasis  rather  than  a  transmigration  of  fluids. 
This  is  so  true  th^t,  when  it  does  not  appear  in  its  ordinary,  that  is, 
critical  form,  it  is  upon  the  nervous  system  alone  that  this  deviation  of 
activity  is  concentrated,  and  some  disorder  of  nervous  function  is 
manifested. 

So  long  as  the  function  of  menstruation  is  accomplished  normally  in 
all  its  conditions,  there  is  nothing,  quoad  this  function,  to  disturb  the 
harmonious  balance  of  the  nervous  system.  But  let  the  function  be 
attended  with  pain,  shock  to  the  nervous  centres  is  inevitable;  and 
it  is  henceforth  only  a  question  of  time,  how  long  the  brain  and  spinal 
cord  will  withstand  the  irritation  of  continuous  or  intermittent  pain- 
ful impressions,  before  the  healthy  equilibrium  is  overturned,  and 
before  morbid  deviations  of  nervous  energy  become  manifested.  The 
time  of  resistance  will  vary  with  the  absolute  and  relative  force  of  the 
two  factors  at  work.  If  we  look  upon  the  nervous  centres  as  the  resist- 
ing or -conservative  power,  and  the  aberration  of  the  menstrual  function 
.as  the  assailing  power,  it  is  obvious  that,  wliere  the  nervous  system  is 


SENILE    DISORDERS.  249 

robust,  pain  will  make  less  severe  impressions  and  slower  inroads ;  and 
that,  on  the  other  hand,  where  the  nervous  centres  are  very  susceptible, 
pain  is  felt  more  acutely,  and  will  sooner  break  down  the  conserva- 
tive resistance.  In  practice  we  may  see  frequent  illustrations  of  this 
proposition.  Dysmenorrhoea,  at  first,  leaves  but  an  evanescent  depres- 
sion ;  after  a  time,  the  prostration  and  nervous  irritability  are  continu- 
ous, only  remittent  in  degree ;  later  still,  attacks  of  hysteria,  neuralgia, 
and  other  nervous  disorders  are  developed,  and  the  general  health 
breaks  down  under  the  continual  wear  and  tear  and  perverted  dis- 
tribution of  the  nervous  power. 

The  subject  of  the  connection  of  hysteria  with  ovarian  influence  has 
been  discussed  in  Chapter  XXI,  on  "  Ovarian  Dysmenorrhoea." 


CHAPTER  XXV. 

THE  DISOKDEKS  OF  SENILITY  OR  DECREPITUDE. 

Following  upon  the  description  of  the  disorders  of  the  climacteric 
period,  we  may  most  conveniently  notice  some  of  those  which  more 
especially  arise  in  advanced  life. 

As  the  ovaries  and  uterus  pass  into  atrophy,  and  shrink,  the  woman 
may  be  said  to  become  asexual.  The  economy  is  no  longer  dominated 
by  the  sexual  apparatus.  Some  women  continue  to  lay  up  fat,  and  in 
these  the  gastric  troubles  increase.  Others  emaciate,  the  fat  is  absorbed ; 
and  as  the  "  padding "  disappears,  the  pelvic  organs,  wanting  their 
external  support,  tend  to  fall  through.  Hence  the  "  senile  prolapse," 
which  is  especially  prevalent  amongst  women  who  are  compelled  to 
lead  a  laborious  life. 

The  atrophy  of  the  uterus  not  seldom  involves  the  obliteration  of  its 
cavity,  or  more  frequently,  atresia  at  certain  points  of  the  canal.  This 
closure  is  especially  liable  to  happen  at  the  os  internum,  and  at  the  os 
externum.  This  last  condition  is  not  at  all  uncommon.  The  vaginal- 
portion  shrinks  away ;  the  os  contracts  to  a  point,  sometimes  closing 
altogether.  At  the  same  time  the  vagina  also  undergoes  a  kind  of 
atrophy ;  the  roof  is  contracted,  and  gives  to  the  examining  finger  the 
sensation  of  a  funnel-shaped  cul-de-sac,  in  the  centre  of  which  the 
small  dimple-like  os  uteri  is  felt.  The  mucous  membrane  is  often  pale; 
the  tissues  have  lost  elasticity. 

The  uterine  mucous  membrane  is  now  liable  to  what  may  be  called 


250  SENILE     DISORDERS. 

senile  catarrh.  There  is  a  chronic  secretion  of  mucus  which,  when 
moderate  in  quantity,  and  not  impeded  in  excretion,  may  entail  little 
distress.  But  it  not  infrequently  happens  that  through  the  atrophic 
atresia  of  the  os  externum,  the  mucus  secreted  in  the  uterine  cavity  is 
retained.  In  this  case,  colic  and  other  consequences  similar  to  those 
which  characterize  retention  of  menstrual  secretion  arise.  The  remedy 
is  similar.  It  consists  in  dilating  the  closed  os  by  incision  or  by  lami- 
naria-tents ;  and  then  astringents  can  be  applied  to  the  uterine  mucous 
membrane. 

This  chronic  senile  catarrh  is  very  often  a  continuation  of  catarrh 
which  began  at  an  earlier  period.  The  discharge  is  sometimes  muco- 
purulent. In  this  case  there  is  often  some  persistent  hypertrophy  of 
the  vaginal-portion.  The  margin  of  the  os  uteri  commonly  shows  a 
ring  of  intense  red  color.  This,  says  Whitehead,  is  a  sure  sign  of 
endometritis. 

There  are  various  troublesome  affections  of  the  skin  which  appear  at 
and  after  the  climacteric  period.  Alibert  observed  many  skin-eruptions 
only  twice  during  life ;  that  is,  before  the  appearance  of  menstruation, 
and  after  its  cessation.  The  predisposing  cause  appears  to  reside  in  the 
unhealthy  state  of  the  blood  and  nervous  system,  which  underlies  so 
many  of  the  climacteric  troubles.  Amongst  other  evidences  of  this  we 
see  a  greater  disposition  to  gout,  rheumatism,  and  neuralgia.  A  transient 
form  of  erysipelas  is  not  uncommon.  Eczema  of  the  vulva  is  almost 
peculiar  to  the  critical  age.  It  succeeds  sometimes  to  intertrigo,  the 
result  of  prolonged  contact  and  chafing  of  skin-surfaces.  Hence  this 
is  most  frequent  in  adipose  women,  in  whom  great  accumulations  of  fat 
cause  overlapping  dependent  rolls  of  skin.  Thus,  "■  the  double-chin 
in  the  belly"  produces  a  large  surface  of  contact  at  the  lower  abdomen, 
groins,  and  upper  part  of  the  thighs ;  between  the  labia  majora  and  the 
thighs  a  similar  condition  occurs;  the  large  flabby  hanging  breasts 
cause  similar  chafing  surfaces  on  the  chest;  another  seat  is  the 
arm-pits ;  another  behind  the  ears.  This  affection  is  in  many  respects 
analogous  to  that  which  is  seen  in  very  fat  infants  not  carefully  treated. 
The  immediate  causes  are :  the  screening  of  the  skin  from  its  wonted 
exposure  to  the  air,  and  consequent  tendency  to  assume  the  characters 
of  mucous  membrane ;  the  friction  of  the  opposed  surfaces  leading  to 
shedding  of  epithelium  scales,  retention  of  dirt,  and  increased  heat. 
The  principle  of  treatment  is  clear.  Prevent  the  contact  of  the  skin- 
surfaces  ;  observe  perfect  cleanliness  and  dryness.  A  good  belt  to  lift 
up  the  lower  abdominal  fold  is  essential.  During  the  stage  of  acute 
inflammation,  marked  by  red  raw  surface  and  secretion,  lotions  of  lime- 
water  with  olive  oil,  bismuth,  oxide  of  zinc,  lead,  glycerin,  applied  on 
pieces  of  smooth  lint,  so  as  to  preserve  the  opposing  folds  from  contact, 
offer  the  most  relief. 

Eczema  of  the  vulva  sometimes  succeeds  to  intertrigo,  these  depend- 
ing on  similar  conditions.  But  the  most  troublesome  form  of  it  is  in- 
dependent of  this  antecedent.  It  affects  chiefly  the  folds  between  the 
labia  majora  and  the  thighs.  In  its  acute  stage  it  entails  a  burning 
itching  sensation  and  thickening  of  the  labia  majora.  The  part  is  deep- 
red,  often  purple,  and  covered  with  minute  dark  spots  caused   by 


SENILE     DISOEDERS.  251 

scratching.  There  is  commonly  a  serous  oozing  from  the  surface.  The 
affection  is  exceedingly  distressing ;  obstinate  under  treatment  owing  to 
its  situation,  the  heat  of  the  part  and  the  difficulty  of  maintaining 
cleanliness  if  the  subject  be  very  stout.  It  is  not  seldom  aggravated, 
if  not  greatly  induced  by  an  acrid  discharge  from  the  vagina. 

This  condition  is  often  attended  by  a  fulness  of  the  pelvic  vascular 
system,  giving  a  dark-red  or  purple  hue  to  the  luucous  membrane  of 
the  vagina.  There  is  chronic  hypersemia,  a  degree  of  stagnation  in  the 
vessels,  owing,  no  doubt,  to  engorgement  of  the  portal  system,  of  the 
venous  system  generally,  and  an  enfeebled  heart. 

This  local  vascular  hypersemia  often  aggravates  the  preceding  and 
following  affections. 

Pruritus  of  the  Vulva. — This  most  distressing  and  obstinate  complaint 
is  sometimes  due  to  disorders  of  nutrition.  In  many  cases  it  is  ac- 
companied by  a  gouty  diathesis  (Gueneau  de  Mussy) ;  in  others  (Dr. 
Charles  West)  by  diabetes.  In  such  cases  it  is  obvious  that  we  must 
not  rely  upon  local  remedies  alone ;  we  must  treat  the  complicating 
diseases  as  well. 

Arsenic,  in  small  doses,  is  often  eminently  useful.  In  the  acute 
stage,  emollient  baths  with  poppy-heads,  laurocerasus,  belladonna,  aco- 
nite may  be  tried.  Now^  and  then,  pulverized  water,  charged  wdth 
belladonna,  will  be  found  useful  in  allaying  irritation.  Weak  solutions 
of  bichloride  of  mercury,  alkalies,  especially  lime-water  with  oil, 
glycerin  w"ith  calomel,  tannin,  or  benzoin,  borax,  bismuth,  or  oxide  of 
zinc  will  all  in  turn  or  in  some  cases  be  serviceable. 

In  the  chronic  form,  strong  sulphur  baths  or  some  hyposulphite 
baths,  as  those  of  Aix,  are  useful.  Dr.  Thomas  Chambers  tells  me  he 
has  seen  great  benefit  from  the  application  of  a  pasma  formed  of  flowers 
of  sulphur  and  w^ater.  Pomade  made  with  mercury  and  belladonna  is 
sometimes  of  service. 

Dr.  Gueneau  de  Mussy  extols  an  ointment  of  bismuth,  bromide  of 
potassium,  calomel,  and  extract  of  belladonna,  made  up  with  glycerinum 
amyli. 

The  painful  excrescence  of  the  meatus  urinarius  is  a  disease  chiefly 
observed  during  the  ages  of  the  climacteric  and  of  decrepitude. 

It  is  during  the  period  of  the  atrophic  process,  or  often  before  it  has 
fairly  set  in,  that  the  uterus  is  so  peculiarly  exposed  to  the  invasion  of 
cancerous  degeneration ;  and  it  is  chiefly  at  this  period  that  malignant 
disease  of  the  labia  vulvae  arises. 

In  treating  of  the  Diseases  of  the  Ovaries,  Uterus,  and  Vulva,  these 
affections  will  be  more  fully  described. 

Women,  even  to  extreme  old  age,  may  be  subjects  of  uterine  hemor- 
rhages, which  cannot  be  traced  to  any  local  disease.  This  has  been 
already  referred  to  in  a  preceding  chapter.  The  fact  is  important  to 
bear  in  mind,  since  hemorrhages  at  this  period  of  life  always  give  rise 
to  the  fear  that  malio-nant  disease  exists. 


252  OVARIAN    DISPLACEMENTS. 


CHAPTER  XXYI. 

OVARY:    ABSENCE  OF  ABNORMAL  CONDITIONS  OF, 
DISPLACEMENT;    HERNIA. 

Both  ovaries  are  hardly  ever  absent,  unless  when  there  is  defect  of 
the  whole  sexual  apparatus.  They  commonly  exist  well  developed 
when  the  uterus  is  absent.  Deficiency  of  one  ovary  is  rarely  observed 
when  the  rest  of  the  sexual  organs  are  well  developed.  When  an  ovary 
is  wanting,  the  Fallopian  tube  of  the  same  side  is  also  wanting,  or  is 
only  represented  by  a  solid  cord  running  from  the  uterus.  Occasionally, 
says  Rokitansky,  an  ovary  may  be  missing  from  having  been  twisted 
off  by  a  process  of  atrophy,  through  dragging  upon  its  attachments, 
and  then  sometimes  a  bit  of  the  tube  has  gone  with  it. 

Atrophy  of  the  ovaries,  independently  of  the  normal  involution  at 
the  climacteric,  is  not  seldom  observed  within  the  period  of  childbearing 
as  the  result  of  exhausting  diseases.  The  existing  follicles  shrink  away, 
new  ones  are  not  formed,  and  the  stroma  retracts ;  on  the  surface  all  trace 
of  recent  scar  is  wanting. 

Displacements  of  the  Ovary. 

The  ovary  is  subject  to  various  displacements.     These  arise  : 

1.  From  changes  in  its  own  condition,  as  of  bulk,  the  result  of  in- 
flammation or  other  disease. 

2.  From  pressure  of  other  organs  or  structures  upon  it,  as  tumors. 

3.  From  dragging  of  the  uterus. 

■  4.  From  inflammatory  adhesions  binding  it  down  in  unnatural  posi- 
tions. 

5.  From  relaxation  of  the  vagina  and  other  structures,  which  support 
the  uterus  and  ovaries  in  situ. 

1.  Displacements  of  the  Ovary  from  its  altered  bulk. — The  most  fre- 
quent, or  at  least  the  most  familiarly  known,  are  the  displacements 
which  ensue  upon  enlargement  of  the  ovary  from  cystic  disease.  I 
must  refer  to  the  chapters  on  Ovarian  Dropsy  for  further  description 
of  the  displacements  from  this  cause. 

Slightly  increased  bulk  and  weight,  acting  concurrently  with  the  re- 
laxation induced  by  morbid  action,  may  cause  the  ovary  to  drop ;  and 
if  it  drop,  it  must  fall  into  the  recto-uterine  pouch,  tending  to  get  be- 
hind the  uterus.  This  movement  from  the  lateral  position  towards  the 
median  line  is  the  necessary  result  of  its  attachments.  The  ovary  is 
suspended  at  the  side  of  the  uterus  on  a  plane  posterior  to  this  organ 
by  a  cord  represented  by  the  Fallopian  tubes  and  ovarian  ligament. 
As  the  ovary  descends  it  describes  an  arc,  of  which  this  cord  is  the 
radius;  and  thus,  unless  the  uterus  desceuds  pari  passu,  the  ovary  must 
come  behind  it. 


OVAHIAl^r    DISPLACEMENTS.  253 

This  has  been  called  prolapsus  of  the  ovary  by  Rigby  and  others. 
It  gets  between  the  rectum  and  the  uterus.  It  is,  says  Kigby,  of  great 
practical  importance,  producing  intense  suffering.  There  is  a  peculiar 
sickening  pain  about  the  sacral  region  extending  to  one  or  other  groin, 
and  coming  on  in  paroxysms  of  agonizing  severity.  Sometimes  there 
are  intermissions  ;  at  others  only  remissions.  The  source  of  the  pain 
is  connected  with  the  rectum,  the  passage  of  faeces  being  difficult  and 
painful.  The  patient  describes  it  as  a  sense  of  obstruction  up  the  rectum. 
Rigby  likens  it  to  orchitis.  There  is  throbbing,  sense  of  bursting, 
aggravated  by  menstruation  and  coagula;  the  stomach  is  irritable, 
vomiting  being  frequent.  Great  pain  is  felt  on  touching  the  os  uteri, 
but  this  is  owing  to  pressing  the  cervix  back  upon  the  ovary.  If  the 
finger  is  pressed  behind  the  os,  either  by  vagina  or  rectum,  it  touches 
the  painful  spot  directly ;  the  oval  movable  ovary  is  then  felt.  It  is 
almost  necessarily  enlarged  by  the  strangulation  caused  by  the  dis- 
placement. The  ovary  may  be  fixed  in  this  abnormal  position  by 
adhesions. 

The  symptoms  above  described  are  mostly  due  to  inflammation, 
which  may  be  either  primary  or  secondary  upon  the  displacement. 
Whether  there  be  inflammation  or  not,  dyspareunia  is  an  almost  con- 
stant consequence. 

Simple  prolapsus  occurs  in  women  of  lax  fibre,  prone  to  constipa- 
tion, to  passive  menorrhagia  and  leucorrhoea. 

An  essential  point  in  the  treatment  is  to  rouse  the  liver,  to  clear  the 
intestinal  canal  by  salines  and  occasional  alteratives.  When  the  pain 
is  great  on  touch,  opiate  suppositories  or  sedative  pessaries  should  first 
be  tried,  unless  we  are  satisfied  there  is  inflammation.  In  this  event 
leeches  to  the  posterior  fundus  of  the  vagina  will  probably  be  useful. 

2.  Displacements  from  'pressure  of  other  structures. — Enlargement  of 
the  uterus  from  a  tumor  in  its  walls  may  displace  the  ovary  in  various 
ways. 

The  ovaries  naturally  follow  the  uterus  in  many  of  the  displacements 
of  this  organ,  as  when  a  retro-uterine  hsematocele  pushes  it  forwards 
against  the  symphysis  pubis.  But  as  their  relative  position  to  the 
uterus  may  be  preserved,  this  change  of  position  does  not  of  itself 
involve  any  particular  symptoms,  although  the  displacing  cause  may 
exert  such  pressure  upon  the  ovaries  as  to  cause  pain  in  them. 

3.  Displacement^^  of  the  Ovary  from  dragging  of  the  Uterus. — If  the 
uterus  descend,  the  ovaries  must  follow,  unless  we  imagine  the  Fal- 
lopian tubes  and  ovarian  ligaments  to  stretch.  In  prolapsus  of  the 
uterus  the  ovaries  will  be  drawn  down,  preserving  their  relative  posi- 
tion behind  the  uterus.  They  are  thus  brought  more  within  reach 
of  the  finger  examining  by  the  rectum. 

The  uterus  may  be  carried  up  into  the  abdomen,  as  in  pregnancy. 
The  ovaries  then  follow,  dropping,  however,  a  little  to  the  sides  of  the 
uterus.  The  uterus  may  also  rise  out  of  the  pelvis,  owing  to  enlarge- 
ment from  tumors  in  its  cavity  or  walls. 

Retroversion  and  retroflexion  of  the  uterus,  by  dragging  on  the  Fal- 
lopian tubes  and  broad  ligaments,  must  pull  somewhat  upon  the  ova- 
ries, and  in  some  cases  the  displacement  thus  effected  is  considerable. 


254  OVARIAN    DISPLACEMENTS. 

The  effect  of  displacement  of  the  fundus  uteri  is  well  seen  in  cases  of 
inversion.  The  descending  fundus  drags  upon  the  tubes,  tends  to  draw 
them  into  its  inverted  cavity,  and  the  ovaries  are  drawn  inwards  to- 
wards the  same  centre. 

Hernia  of  the  Ovary. — When  the  ovary  enters  into  the  contents  of  a 
hernial  sac  it  is  generally  the  result  of  a  congenital  vice.  The  most 
common  form  is  the  inguinal,  but  the  ovary  has  been  found  in  crural, 
abdominal,  vaginal,  subpubic,  and  even  ischiatic  hernise.  Observed 
cases  permit  the  following  conclusions  to  be  drawn :  The  pain  which 
attends  these  hernise  extends  from  the  seat  of  the  strangulation  to  the 
uterus,  and  thus,  if  by  the  finger  in  the  vagina  we  move  the  uterus, 
this  movement  is  transmitted  to  the  contents  of  the  hernia.  In  one- 
sided ovario-inguinal  hernia,  the  fundus  of  the  uterus  is  slightly  in- 
clined to  the  side  of  the  hernia,  and  Seller  has  drawn  attention  to  the 
fact  that  the  pains  in  the  hernial  sac  increase,  and  are  attended  by  a 
feeling  of  dragging,  when  the  patient  lies  down  on  the  opposite  side. 
The  ovaries  may  be  felt  to  swell  and  become  more  tender,  as  was  di- 
rectly observed  by  Scanzoni,  in  the  remarkable  case  already  referred  to 
under  "Menstruation"  (see  page  160).  Boivin  and  Duges  feared  that 
ovarian  hernia  would  either  induce  sterility  or  lead  to  extra-uterine 
gestation.  Since  Mr.  Curling  has  shown  that  hernia  of  the  testicles 
induces  sterility  in  the  male,  the  first  conjecture  seems  strengthened. 
But  Scanzoni's  patient  became  pregnant. 

Treatment. — When  the  hernia  is  reducible,  the  taxis  and  a  suitable 
bandage  should  be  applied.  But  if  the  ovary  be  fixed  by  adhesions  it 
may  be  wise  to  follow  the  example  of  Pott,  whose  case  I  have  also  re- 
ferred to  under  "  Menstruation,"  and  of  Deneux.^ 

Enlargement  of  the  ovary  is  mostly  the  result  of  textural  disease. 
To  this  category  belongs  the  excessive  growth  of  the  follicles,  resulting 
in  cysts. 

4.  Anomalies  of  relation  are  frequently  seen  in  the  form  of  'pseudo- 
membranous adhesions  of  the  ovaries.  The  most  common  is  the  adhe- 
sion with  the  tube ;  next  in  frequency  is  the  adhesion  of  the  ovary, 
either  with  or  without  its  tube,  to  the  hinder  wall  of  the  uterus,  and 
the  neighboring  parts  of  the  ligamentum  latum  down  to  the  bottom  of 
the  recto-vaginal  pouch.  These  adhesions  frequently  result  from  puer- 
peral peritonitis  at  a  time  when  the  uterus  is  above  the  usual  size, 
filling  the  pelvic  cavity,  and  when  its  appendages  are  thrown  back  to 
its  posterior  surface.  Adhesions  of  the  ovaries  also  take  place  to  the 
sides  of  the  pelvis,  to  the  rectum,  to  the  sigmoid  flexure,  in  conse- 
quence of  pelvic  peritonitis  to  which  anomalous  maturation  and  morbid 
processes  in  the  ovaries  or  tubal  catarrh  has  given  rise. 

Peritonitis  determining  adhesions  of  this  kind  may  also  be  caused 
by  retro-uterine  hsematocele.  When  the  blood-tumor  disappears,  the 
relation  of  the  ovaries  and  uterus  may  thus  remain  altered  for  a  time. 

Rokitansky  says  the  ligamentum  ovarii  may  undergo  stretching  and 
separation  in  childhood,  and  even  in  the  foetal  state,  in  consequence  of 
adhesions  then  acquired,  and  that  separation  of  the  ovary  from  the 


1  "  Kecherches  sur  les  Ilernies  de  I'Ovaire."     Paris,  1813. 


ovary:   cystic  degeneration.  255 

uterus  may  thus  result.  It  will  then  degenerate,  and  may  be  fixed  at 
its  place  by  adhesion,  or  loose.  Sometimes  it  vanishes,  leaving  no 
trace  behind.  When  the  ovary  has  contracted  adhesions  it  is  subject 
to  dragging  from  the  rising  gravid  uterus,  or  from  the  uterus  growing 
together  with  the  developing  pelvis,  also  from  the  development  of 
the  bladder,  sigmoid  flexure,  or  rectum.  This  dragging  commonly 
causes  atrophy  of  the  ovary. 


CHAPTER  XXyil. 

OVAKY:    HYPEE^MIA,  HEMOREHAGE,  AND  ANOMALIES  OF 
THE  CORPUS  LUTEUM. 

Hyperemia  of  the  ovary  attends  the  normal  as  well  as  the  ab- 
normal ripening  and  extrusion  of  ova  and  the  results,  and  especially 
affects  the  stroma  surrounding  the  peripheral  follicles,  and  their  fibrous 
cavities.  The  involution  of  the  follicle  following  on  the  completion 
of  the  menstrual  antecedents  is  also  often  marked  by  a  considerable 
vascularity  of  the  surrounding  tissues. 

Menstrual,  as  well  as  extra-menstrual,  congestion  excites  in  the  pe- 
ripheral, as  well  as  in  the  deep-lying  follicles,  an  excessive  growth  and 
cystic  degeneration.  Very  often  it  leads  to  hemorrhage,  principally 
in  the  large  peripheral  follicles ;  then  there  are  found  one  or  more  pro- 
jecting sacs  filled  with  lightly  coagulated  blood,  and  varying  in  size 
from  a  bean  to  a  nut,  or  even  to  a  fist.  They  shrink  after  the  manner 
of  corpora  lutea,  and  sometimes  after  the  resorption  of  the  extravasated 
blood  they  remain  as  cysts  and  continue  to  grow. 

The  anomalies  observed  in  the  corpus  luteum  are,  according  to 
Rokitansky — 1.  Dendritic  protrusion  of  the  corpus  luteum  outwards 
through  the  rent  of  the  follicle.  This  appears  as  a  villous,  soft, 
reddish-yellow  outgrowth  continuous  with  the  mass  of  the  yellow  body, 
or  as  a  leaf-like  excrescence  connected  by  a  branched  stalk,  on  which 
are  small  linseed-formed  white  fibrous  bodies. 

2.  Duplication  of  the  corpus  luteum,  which  Rokitansky  explains 
thus  :  A  fresh  hemorrhage  takes  place  prematurely  from  the  wall  of  a 
follicle  after  the  formation  of  one  corpus  luteum,  which  detaches  the 
yellow  body,  pushing  it  inward,  and  hereupon  a  second  corpus  luteum 
is  formed  in  the  wall  of  the  follicle. 

Rokitansky  describes  the  following  degeneration  of  the  corpus  luteum, 
1.   Cystic  degeneration.     The  cyst  in  the  periphery  of   the  ovary   is 


256 


OVARY. 


found  retaining  traces  of  the  structure  of  the  corpus  luteum,  including 
the  scar  of  the  rent,  although  it  may  be  as  large  as  a  walnut.  With 
these  cysts  there  is  occasionally  seen  the  remarkable  appearance  of  a 
primitive  communication  of  the  cyst  with  the  fimbriated  extremity  of 
the  Fallopian  tube,  resulting  from  the  process  of  extrusion  of  the 
ovum  from  the  follicle  and  its  reception  into  the  tube.  These  are  the 
so-called  tuho-ovarian  cysts  which  have  been  described  by  Richard. 
(See  Fig.  79,  from  Carswell.) 

2.  The  degeneration  to  a  fibrous  tumor,  which  consists  in  the  excessive 
growth  of  the  yellow  body  and  its  persistence  m  the  form  of  a  more 
or  less  plainly  visible  sheath  inclosing  round  fibrous  knots  the  size  of  a 
walnut,  and  a  cavity  filled  with  serum. 


Showing  a  blood  coagulum  in  a  cyst  of  ovary.    (Guy's,  2228^.) 

"  The  ovary  forms  a  cyst  with  thick  waBs,  and  contains  what  appears  to  be  a  coagulum  of  blood  as 

large  as  a  chestnut." — (Catalogue.) 


The  specimen  figured  (Fig.  QQ)  seems  to  be  an  example  of  this  fibrous 
degeneration  of  a  Graafian  follicle. 

3.  The  degeneration  to  carcinoma  may  ensue  upon  the  preceding 
fibrous  degeneration. 

"  Oophoralgia,'^  "neuralgia  of  the  ovary,''  "ovarian  irritation,"  is  an 
aifection  so  often  mistaken  for  inflammation  that  it  is  desirable  to  dis- 
cuss it  in  the  same  connection.  It  is  an  extremely  distressing  disorder, 
apt  to  last  for  years,  and  to  embitter  existence.  It  occurs  in  the  single 
as  well  as  in  the  married,  but  more  frequently  in  the  married.  It  is 
often  associated  with  tlie  hysterical  temperament,  and  almost  always 
with  an  induced  increase  of  irritability  of  the  nervous  centres.     It  is 


OOPHORALGIA. 


257 


marked  by  intense  exacerbations  at  the  menstrual  periods.  The  pain 
in  the  ovarian  region  is  then  so  acute  as  to  simulate  oophoritis  or  peri- 
tonitis; the  pulse  rises  in  frequency  and  the  skin  in  temperature.  But 
mere  pain  is  enough  to  induce  these  conditions.     Local  examination 


Fig.  6G. 


Fibrous  tumor  of  ovary  from  a  woman  set.  50.     (St.  George's, 

XIV,  140.    Nat.  size.) 

The  uterus  also  contaiued  a  fibrous  tumor. 


reveals  a  swollen  condition  of  the  ovaries,  often  considerable,  that  is, 
to  twice  the  ordinary  size,  or  even  more;  the  patient  complains  of  ex- 
quisite pain  when  the  ovary  is  compressed  between  the  finger  internally 
and  the  hand  outside,  and  also  by  mere  digital  touch  on  its  side  of  the 
uterus.  Touching;  the  neck  of  the  uterus  in  such  a  manner  as  to  lift 
up  the  body  of  the  organ,  or  to  move  it  to  either  side  evokes  pain. 
This  is  partly  due  to  concomitant  congestion  and  tenderness  of  the 
uterus  itself,  this  organ  becoming  more  sensitive  in  consequence,  and 
partly  to  the  moving  uterus  disturbing  the  ovaries.  Touching  the 
ovarian  region  will  sometimes  induce  hysteria,  sometimes  vomiting  as 
W'cll  as  pain. 

The  monthly  repetition  of  these  attacks  rarely  fails  to  induce  such  a 
state  of  nervous  irritability  and  exhaustion  that  the  sufferer  loses  appe- 
tite, nutrition  is  impaired,  and  she  is  compelled,  or  thinks  she  is  com- 
pelled, to  abandon  all  exercise,  and  comes  to  regard  herself  as  a  con- 
firmee! invalid.  Dyspareunia  is  a  never-failing  consequence,  and  this 
adds  to  the  mental  and  physical  distress. 

The  character  of  the  menstrual  flow  varies.  Not  seldom  it  is  in  ex- 
cess, but  sometimes  it  is  not  so.  Dysmenorrhoea  is  a  frequent,  but  not 
a  constant  concomitant.  In  many  cases  it  may  be  said  to  arise  out  of 
dysmenorrhoea.  The  ovarian  irritation  is  the  expression  of  difficult 
ovulation. 

17 


258  OVARY. 

That  these  cases  are  especially  apt  to  pass  into  inflammation  is  highly 
probable.  There  is  congestion  of  the  ovaries,  tubes,  and  uterus  beyond 
the  physiological  measure,  so  that  escape  of  blood  into  the  peritoneum 
is  not  unlikely  to  occur.  But  that  the  symptoms  related  indicate  in- 
flammation it  would  be  wrong  to  assume.  The  intensity  of  the  pain  is 
not  evidence  of  inflammation.  I  have  known  an  ovarian  cyst  burst, 
discharge  its  contents  into  the  peritoneal  cavity,  and  death  ensue  under 
the  most  excruciating  agony ;  yet  examination  has  not  shown  a  trace 
of  inflammation.  Again,  in  these  cases  we  find  the  uterus  remaining 
movable,  entire  absence  of  any  thickening  or  perimetric  swellings,  even 
after  years  of  suffering.  It  may  be  true  that  the  ovary  proper  may  be 
inflamed  alone,  but  it  is  hardly  conceivable  that  repeated  attacks  of 
oophoritis  should  always  fail  to  involve  the  peritoneal  investment.  It 
is,  moreover,  scarcely  in  accordance  with  the  history  of  inflammation  to 
return  in  an  organ  every  month,  to  run  its  course  in  a  few  days,  and  to 
leave  the  organ  essentially  sound,  that  is,  in  a  condition  ultimately  to 
perform  its  functions.  Yet  I  have  seen  cases  where  this  oophoralgia 
lasted  for  years,  was  cured,  and  healthy  menstruation  ultimately  estab- 
lished. 

The  ascertained  conditions  are  extreme  local  hypersemia,  or  conges- 
tion, and  exquisite  sensibility  of  the  ovaries,  combined  with  great  irri- 
tability of  the  nervous  centres. 

These  conditions  furnish  the  indications  in  treatment.  It  is  very 
important  to  eliminate  the  idea  of  inflammation  where  the  thing  does 
not  exist,  because  antiphlogistic  treatment  will  in  the  long  run  aggra- 
vate the  disease,  and  reduce  the  general  powers.  Thus  I  have  several 
times  seen  great  prostration,  increase  of  local  hyperesthesia  and  of  gen- 
eral local  irritability  produced  by  the  repeated  application  of  leeches  to 
the  groins  or  to  the  os  uteri.  It  is  true  that  in  some  of  these  cases  the 
patients  expressed  relief  at  the  time ;  but  the  relief  could  hardly  be  said 
to  be  real ;  it  was  not  attended  by  cure,  and  seemed  to  me  to  do  more 
harm  than  good.  Counter-irritation  in  the  form  of  blisters,  or  chloro- 
form-embrocations to  the  iliac  regions,  has  appeared  to  be  beneficial. 

Another  proceeding  very  apt  to  be  carried  to  a  mischievous  excess  is 
lying  down.  Nutrition  must  suifer,  and,  as  a  consequence,  the  nervous 
centres  become  more  irritable. 

The  true  course  to  adopt  is  to  follow  the  three  indications  given  by — 
1.  The  general  depression  of  the  system ;  2.  The  exaggerated  irrita- 
bility of  the  nervous  centres ;  3.  The  excessive  congestion  and  hyper- 
sesthesia  of  the  ovaries  and  surrounding  parts. 

It  is  superfluous  to  enumerate  the  medicinal,  dietetic,  and  hygienic 
remedies  which  help  to  fulfil  the  first  indication.  The  task  of  allaying 
the  extreme  irritability  of  the  nervous  centres  will  be  made  easier  in 
proportion  as  the  general  tone  is  improved.  The  nervous  centres  Avill 
also  recover  power  as  the  third  indication,  that  of  tranquillizing  the 
ovaries,  one  source  of  irritation,  is  effected. 

Rest  in  the  physiological  sense,  that  is,  abstinence  from  "  married 
life "  is  imperative.  To  subdue  the  hypersesthesia,  the  wearing  for  a 
few  hours  every  day  one  of  the  forms  of  "  vaginal-rest "  will  be  found 
of  great  service.     If  there  is  any  displacement  of  the  womb  this  must 


INFLAMMATION.  259 

be  corrected  by  suitable  means.  Abrasion,  congestion  of  the  cervix 
uteri,  must  be  cured.  I  liave  found  it  useful  to  eiFect  a  derivative  action 
in  the  cervix,  by  making  a  small  eschar  on  the  vaginal-portion  Avith 
potassa  cum  calce.  This  is  far  less  painful  and  more  efficacious  than 
blistering  the  groins.  Bromide  of  potassium  acts  in  some  degree  as  a 
sedative  of  ovarian  excitement ;  but  it  is  not  to  be  depended  upon  alone. 
The  bowels  must  be  well  regulated  to  prevent  accumulation  in  the  rec- 
tum. Salt-water  or  Vichy  baths,  tepid  or  cold,  according  to  the  season, 
are  often  eminently  useful. 

The  treatment  must  be  pursued  steadily.  Time  is  required  to  bring 
about  a  healthier  innervation,  and  to  improve  the  nutrition  of  all  the 
tissues. 

The  case  under  discussion  not  seldom  falls  under  the  category  of 
dysmenorrhcea,  and  the  treatment,  of  course,  is  directed  by  the  indica- 
tions arising  in  this  connection. 

Great  relief  is  often  obtained  by  the  use  of  sedative  pessaries  contain- 
ing opium  or  belladonna  applied  to  the  fundus  of  the  vagina  a  day  or 
two  before  the  advent  of  the  exacerbation  due  to  the  menstrual  epoch. 

Inflammation  of  the  Ovary. 

It  is  not  within  the  scope  of  this  work  to  describe  the  diseases  of  the 
puerperal  state.  I  pass  over  therefore  those  forms  of  oophoritis  with 
which  pathological  anatomists  are  most  familiar.  The  oophoritis  of 
childbed  is  seldom  met  with,  perhaps  never,  apart  from  complication 
with  inflammation,  extending  from  the  uterus,  tubes,  and  broad  liga- 
ments. The  ovary  is  not  affected  primarily,  but  is  caught  secondarily 
in  the  spread  of  an  active  inflammation  which  invades  most  or  all  of 
the  pelvic  structures.  It  is  difficult  so  to  isolate  the  oophoritis  in  these 
cases  as  to  extract  any  trustworthy  facts  to  illustrate  the  history  of  pure 
oophoritis.  Nor  do  we  derive  a  much  larger  amount  of  precise  informa- 
tion, ad  hoe,  from  the  examination  of  subjects  who  have  had  oophoritis 
apart  from  childbed.  Here,  too,  the  oophoritis  is  not  often  simple,  but 
a  part  of  an  inflammatory  process  involving  other  structures. 

Simple  oophoritis  is  rarely  fatal ;  so  that  the  opportunities  of  seeing 
the  condition  of  the  ovary  under  the  influence  of  acute  or  recent  in- 
flammation are  necessarily  rare.  I  cannot  help  thinking  that  the 
precise  division  of  oophoritis  into  four  degrees  given  by  Boivin  and 
Duges  is  drawn  rather  from  theoretical  reasoning  than  from  observation. 
Rokitansky  declares  that  apart  from  childbed  oophoritis  is  very  rare. 
But  this  statement  must  be  taken  as  expressing  the  experience  of  the 
dead-house.  I  believe  that  simple,  or  conjoined  with  metritis,  it  is 
not  uncommon.  But  as  the  cases  recover  more  or  less  perfectly,  dis- 
tinct evidence  of  the  inflammatory  action  to  which  the  ovaries  have 
been  subject  is  rarely  seen.  All  such  evidence  had  disappeared  during 
life,  or  had  become  confounded  with  the  results  of  complicating  diseases. 

One  of  the  most  frequent  conditions  found  is  fibrinous  adhesions  of 
various  age  uniting  the  ovaries  to  the  sides  and  posterior  surface  of  the 
uterus,  to  the  broad  ligament,  or  other  neighboring  structures.  These 
are  often  found  in  women  who  have  never  borne  children.     We  are 


260  OVARY. 

thus  driven  to  the  conekision  that  women  are  liable  to  frequent  pelvic 
inflammations  aj)art  from  pregnancy.  These  adhesions  of  course  are 
the  residua  of  peritoneal  inflammation,  and  commonly  extend  beyond 
the  ovaries  to  other  parts  of  the  pelvic  peritoneum. 

The  ovarian  implication  is  often  secondary.  But  it  cannot  be 
doubted  that  there  are  cases  of  primary  oophoritis  proper.  An  organ 
performing  a  function  so  important  as  ovulation,  and  stimulating  the 
Fallopian  tubes  and  uterus  to  share  in  the  work  of  menstruation,  can- 
not be  expected  to  enjoy  immunity  from  inflammation.  All  active 
function  involves  determination  of  blood  to  the  organ  performing  it ; 
but  there  is  no  organ  whose  functional  activity  attracts  blood  in  such 
profusion  as  the  ovary.  It  goes  beyond  simple  transient  hyperaemia ; 
the  rush  and  work  are  so  violent  that  actual  extravasation  of  blood 
and  laceration  of  structure  take  place.  It  cannot  then  be  surprising 
that  under  certain  conditions  interfering  with  the  normal  accomplish- 
ment of  this  function,  activity  so  great  should  pass  the  narrow  physio- 
logical boundary,  and  terminate  in  inflammation.  Obstruction  to  the 
due  discharge  of  the  menstrual  secretion,  sudden  suppression  of  the 
secretion,  undue  excitation  of  the  uterus  and  ovaries  whilst  in  the  exe- 
cution of  this  function,  as  from  excessive  exertion,  sexual  relations,  or 
exposure  to  cold  and  wet,  may  easily  determine  inflammation.  Some- 
times the  uterus,  tubes,  and  pelvic  peritoneum  will  be  seized  along 
with  the  ovaries,  but  at  other  times  the  ovaries  are  chiefly,  if  not  ex- 
clusively affected. 

Scanzoni  describes  the  post-mortem  appearances  in  what  appears  to 
have  been  a  typical  case  of  acute  oophoritis.  The  subject  died  of 
pneumonia,  the  result  of  cold,  and  with  symptoms  of  peritonitis  in  the 
right  ovarian  region.  In  this  situation  was  found  a  mass  of  coagulated 
fibrin,  the  size  of  a  fist.  On  removing  this  the  right  ovary  was  seen 
two  inches  long,  nearly  as  much  across,  and  one  and  a  half  inch  thick. 
It  was  ovoid,  considerably  enlarged,  as  the  measurements  show ;  its 
surface  was  violet-blue,  covered  with  numerous  dilated  veins,  and  near 
the  inner  angle  of  the  jDosterior  surface  was  a  black  spot,  the  seat  of 
recent  rupture  of  a  vesicle.  The  organ  was  pasty,  almost  fluctuating 
in  parts.  On  incision  there  escaped  a  considerable  quantity  of  blood, 
and  the  section  showed  the  same  violet  color,  and  some  veins  strongly 
congested.  The  ruptured  vesicle  still  held  some  liquid  black  blood. 
Towards  the  other  extremity  of  the  ovary,  where  the  congestion  was 
less  intense,  there  was  an  abscess  in  the  i^arencliyma ;  and  at  the  side 
were  other  smaller  abscesses,  all  deej)  in  the  parenchyma.  This  case 
shows  that  there  is  combination  of  all  the  forms  of  oophoritis. 

Causes. — Oophoritis  may  be  said  to  be  almost  strictly  limited  to  the 
reproductive  period  of  life.  It  is  accordingly  found  to  arise  under 
conditions  which  offer  obstruction  to  the  ordinary  course  of  the  ovarian 
function.  Impressions,  physical  or  emotional,  occurring  during  men- 
struation may  goad  the  physiological  congestion  into  inflammation. 
Cold,  excessive  sexual  indulgence,  esjiecially  during  menstruation,  arc 
not  uncommon  causes. 

It  has  followed  operations  on  the  os  uteri,  and  intra-uterine  injec- 
tions, and  the  spread  of  blennorrhagic  inflammation  along  the  Fallo- 


INFLAMMATION,  261 

pian  tubes.  Ricord  described  this  last  form  as  analogous  to  the  orchitis 
arising  from  blennorrhagia  in  the  male.  Its  origin  in  obstructed  men- 
struation will  account  for  the  fact  of  oophoritis  being  more  frequent  in 
virgins  than  inflammation  of  the  uterus,  which  as  yet  has  only  entered 
upon  the  subsidiary  function  of  menstruation. 

It  is  often  secondary  upon  disease  of  the  uterus,  tubes,  and  broad 
ligaments.  The  intimate  vascular  communications  between  these 
organs  offer  a  ready  channel  of  extension  for  inflammation  from  the 
uterus. 

The  dysmenorrhoea  resulting  from  a  contracted  or  nearly  impervious 
OS  uteri,  seldom  exists  for  any  considerable  period  without  inducing 
chronic  inflammation  of  the  ovary. 

Retroversion  is  a  frequent  cause  of  swelling  and  great  tenderness  of 
the  ovary,  not  unfrequently  amounting  to  oophoritis,  from  the  fundus 
of  the  uterus  pulling  the  ovary  backwards,  and  thus  by  the  tension  of 
the  broad  ligaments  producing  obstruction  to  its  returning  circulation. 

Sexual  intercourse  for  the  first  time,  especially  if  there  have  been 
previously  an  irritable  state  of  the  ovary,  with  dysmenorrhcea,  is  not 
unfrequently  followed  by  oophoritis. 

Early  abortions  also  will,  sometimes,  lead  to  the  same  condition. 

Oophoritis,  arising  otherwise  than  in  childbed,  is  often  single.  But 
the  ovaries  appear  to  be  subject,  like  the  eyes  and  other  double  organs, 
to  consensual  suffering.  Thus,  inflammation  of  one  ovary  is  likely  to 
be  followed  by  inflammation  of  the  other.  It  is  in  some  cases  difii- 
cult  to  explain  the  attack  upon  the  second  ovary  by  any  other  than 
the  consensual  hypothesis.  But  in  some  cases  it  is  easy  to  observe 
that  common  predisj^osing  and  exciting  causes  act  upon  both  ovaries 
alike,  although  one  may  be  affected  earlier  and  more  severely  than  the 
other. 

Inflammation  of  the  Follicles  of  the  Ovary. — Apart  from  the  ordinary 
peritoneal  inflammatory  action  proceeding  from  the  ripened  and  burst 
follicles,  one  may  see  one  or  more  ripe  follicles  with  injected  walls,  red, 
softened,  easily  torn,  with  turbid,  flocculent,  puriform  contents,  and 
the  surrounding  parenchyma  infiltrated.  This  leads  to  atrophy  of  the 
follicle,  or  causes  its  degeneration  to  a  cyst. 

Negri er  describes  "  Vesiculite'^  simple.  In  most  cases  the  trouble 
remains  local.  A  point  of  the  ovary  becomes  tumefied  and  torn,  an 
inflammatory  areola  has  surrounded  the  little  wound,  sometimes  has 
invaded  the  peritoneal  investment,  and  even  the  pelvic  peritoneum. 
Vesiculite  is  "simple"  when  easily  stopped,  and  ending  in  resolution. 
V^siculite  is  "grave,"  when  ending  in  suppuration,  or  when  the  in- 
flammation has  spread  widely  to  the  pelvic  peritoneum. 

Kiwisch  says  the  inflammation  of  the  follicles  is  commonly  confined 
to  one  Graafian  vesicle.  An  indication  of  the  inflammatory  process  is 
seen  in  the  menstrual  metamorphosis  of  the  follicles.  The  products  of 
this  inflammatory  condition  are  more  or  less  plastic,  and  in  general 
much  infiltrated  with  blood ;  the  follicle  is  distended  to  the  size  of  a 
pea  or  a  cherry.  When  several  follicles  are  implicated,  the  surround- 
ing stroma  participates  in  the  inflammatory  condition,  and  is  found  in 
a  state  of  hypersemia,  serous  infiltration,  or  inflammatory  softening. 


262  OYARY. 

Pai^enehymatous  Ovaritis. — This  very  rarely  runs  to  suppuration. 
It  often,  however,  leads  in  young  persons  to  peritoneal  false  membranes 
and  adhesions,  to  increase  of  bulk  and  thickening  (sclerosis)  of  the 
stroma,  thickening  of  the  tunica  albuginea,  with  atrophy  of  the  fol- 
licles, especially  of  the  peripheral  ones,  and  enlargement  of  the  ovary, 
with  tuberose  surface. 

Inflammation  of  the  stroma  is  rare  in  the  non-puerperal  state. 
Kiwisch  relates  two  cases  in  which  the  entire  organs  were  aifected,  both 
ending  fatally  in  a  short  time;  in  the  one  by  acute  abscess,  in  the  other 
by  a  sanious  disintegration.  In  both  consecutive  peritonitis  was  the 
cause  of  death. 

Simple  peritoneal  oophoritis  can  hardly  be  said  to  exist.  It  is  peri- 
tonitis, not  oophoritis;  and  the  inflammation  will  rarely  be  limited  to 
the  surface  of  the  ovary.  Ovarian  peritonitis  is  commonly  a  part  of 
the  widespread  pelvic  peritonitis  of  childbed,  or  other  forms  of  gen- 
eral pelvic  peritonitis.  Primary  ovarian  peritonitis  is  more  frequently 
limited  to  one  side,  and  is  the  result  of,  or  attended  by  traumatic  or 
other  lesion  proceeding  from  the  bursting  or  disease  of  a  Graafian  fol- 
licle. But  even  in  such  a  case  the  inflammation  is  very  apt  to  spread 
to  the  peritoneum  beyond  the  ovary. 

Symptoms  and  Diagnosis. — When  oophoritis  is  complicated  with 
metritis  and  pelvic  peritonitis,  its  special  symptoms  are  lost  or  con- 
founded in  those  of  the  attendant  inflammation.  The  peritonitic  sym}> 
toms  especially  preponderate,  and  govern  both  diagnosis  and  treat- 
ment. Where  ovaritis  is  simple,  or  the  chief  morbid  condition,  the 
symptoms  being  more  concentrated,  ought  to  be  more  characteristic. 
But  they  are  not  free  from  ambiguity.  The  local  symjitoms  attending 
many  severe  cases  of  dysmenorrhoea  are  referred  by  the  patient  and 
traced  by  the  physician  to  the  ovary.  Intense  j)ain  in  the  ovarian 
region,  swelling  and  tenderness  of  the  ovary  under  touch,  burning, 
shooting  pain  in  the  pelvis,  pain  in  defecation,  febrile  movement,  in- 
cluding hot  skin  and  quickened  pulse,  suggest  inflammation,  and  seem 
to  fix  that  inflammation  in  the  ovary.  But  these  symptoms  subside 
in  a  few  clays,  as  menstruation  passes  off;  and  if  we  now  examine  the 
ovary  we  may  find  little  or  no  tenderness  or  swelling.  If,  then,  in- 
flammation attended  the  painful  menstruation,  it  was  an  inflammation 
of  a  very  transient  character.  We  can  hardly  conceive  an  inflamma- 
tion of  the  ovary  which  recurs  every  month  throughout  thirty  years, 
and  which  is,  nevertheless,  compatible  with  the  continuance  of  the 
ovarian  function.  These  symptoms,  then,  Avhich  outside  the  menstrual 
epoch  would  be  considered  to  indicate  inflammation  of  the  ovary,  may 
be  produced  by  temporary  hyperemia  and  hyper^esthesia  of  the  organ. 

Pain  in  the  region  of  one  or  other  ovary,  even  if  increased  by  pres- 
sure, is  not  sufficient  evidence  of  oophoritis.  Pain  of  this  character  is 
a  frequent,  almost  constant,  attendant  upon  inflammation  of  the  neck 
of  the  uterus.  It  arises  with  this  disease  and  subsides  with  it.  It  is 
in  like  manner  a  frequent  attendant  upon  obstructive  dysmenorrhoea 
or  the  dysmenorrhoea  of  retention.  In  these  cases  the  pain  must  be 
regarded  as  reflex  or  sympathetic. 

On  the  other  hand,  ovarian  disease  is  very  liable  to  be  overlooked. 


INFLAMMATION".  263 

because  attention  is  likely  to  be  concentrated  on  attendant  uterine 
disease. 

Before  concluding  that  the  ovary  is  inflarued,  we  must  continue  our 
observations  during  the  intermenstrual  ]3eriod.  The  history  of  the 
onset  and  progress  of  the  aifection  will  oflPer  different  points.  If  in- 
tense pain  referred  to  one  or  other  ovarian  region  supervene  quickly  on 
exposure  to  cold,  excessive  venereal  excitement,  emotion,  in  the  course 
of  blennorrhagia,  or  after  operations  on  the  uterus,  or  intra-uterine 
injections,  the  state  of  the  pelvic  organs  should  be  explored  by  internal 
and  external  palpation.  It  is  probable  that  the  uterus  will  be  found 
to  share  in  the  tenderness  and  swelling  which  afPect  the  ovaries;  per- 
haps, too,  the  broad  ligaments  and  pelvic  peritoneum  will  be  involved. 
Where  this  is  the  case,  it  will  be  difficult  to  get  at  the  ovaries,  which 
will  be  surrounded  by  swollen  and  tender  structures.  But  where  the 
ovary  is  principally  affected,  or  when  the  concomitant  affection  of  the 
uterus  and  other  structures  has  subsided,  the  state  of  the  ovary  comes 
into  prominence.  Palpation  supplies  the  only  trustworthy  evidence. 
In  every  examination  per  vaginam,  the  finger  is  first  directed  as  a  point 
of  departure  to  the  os  and  cervix  uteri.  On  touching  this  part,  pain 
will  in  all  likelihood  be  caused,  and  we  may  conclude  that  the  uterus 
is  the  organ  at  fault.  The  pain  may,  however,  be  due  to  the  pressure 
of  the  uterus  upon  the  inflamed  ovary..  We  therefore  seek  to  elimi- 
nate the  uterus  by  pressing  the  finger  gently  against  the  vaginal  roof 
in  front,  at  the  sides  of,  and  behind  the  uterine  neck.  When  pressing 
at  one  or  both  sides  upwards,  the  pain  will  be  greater,  and  we  may 
possibly,  by  conjoint  external  pressure  on  the  abdomen,  embrace  the 
painful  structures  between  the  two  hands.  This  deep  pressure  in  the 
sides  of  the  pelvis  on  the  abdomen  alone  causes  pain,  and  there  is  a 
feeling  of  resistance,  caused  partly  by  the  swelling  of  the  parts,  and 
partly  by  the  muscular  tension  exerted  instinctively  to  ward  off  the 
dreaded  pressure.  But  the  clearest  evidence  of  the  state  of  the  ovary 
is  to  be  attained  by  the  recto-abdominal  touch.  As  Lowenhardt 
pointed  out,  the  ovaries,  especially  if  inflamed,  can  commonly  be 
reached  by  the  finger  in  the  rectum ;  and  this  the  more  surely  if  they  be 
pushed  on  to  the  examining  finger  by  the  hand  pressed  firmly  down 
upon  the  uterus  through  the  abdominal  wall.  We  may  then  recognize 
the  ovary  by  its  form,  position,  mobility,  and  tenderness,  and  judge 
by  its  increased  size,  and  pain  on  touch,  whether  it  is  inflamed  or  not. 
But  the  ovaries,  even  much  enlarged  by  inflammation,  may  be  insensi- 
ble to  considerable  pressure — a  proof,  says  Schultze,  that  oophoritis 
need  not  necessarily  implicate  the  peritoneum. 

Other  signs,  chiefly  subjective,  concur  in  throwing  light  upon  the 
case.  Accumulation  of  fecal  matter  in  the  csecum  will  increase  the 
pain  of  inflammation  in  the  right  ovary,  whilst  the  movements  of  the 
rectum  in  defecation  will  have  the  like  eff'ect  when  the  left  ovary  is 
inflamed.  But  after  all,  a  rigorous  method  of  exclusion  of  inflamma- 
tions in  neighboring  structures  is  necessary  to  justify  a  positive  diag- 
nosis of  ovaritis. 

My  experience  coincides  with  that  of  Schultze,  who  says  that  he  has 
often  observed  that  an  inflamed  ovary,  in  Douglas's  pouch,  lies  in  front 


264  OVARY. 

of  the  uterus  to  the  side,  and  that  after  it  has  recovered  its  normal  vol- 
ume and  sensibility,  it  has  returned  to  its  normal  position.  In  other 
cases  after  recovery  it  maintains  its  abnormal  position,  and  in  one  case 
an  ovary  which  had  been  closely  adherent  to  the  uterus  after  inflam- 
mation, was  several  months  before  it  became  movable  again.  So 
many  of  the  symptoms  supposed  to  indicate  an  oophoritis  may  really 
depend  on  some  form  of  metritis  or  pelvic  peritonitis,  or  some  flexion 
or  other  change  in  the  uterus,  that  we  may  agree  with  Veit  that  the 
diagnosis  of  oophoritis  can  only  be  made  out  with  certainty  when  the 
swollen  and  painful  ovary  can  be  distinctly  felt  as  a  circumscribed 
swelling.  It  is  not  necessary  that  it  should  be  movable;  although  it 
may  be  exceedingly  difficult  to  recognize  an  ovary  when  fixed,  by 
adhesions. 

The  morbid  follicle,  according  to  Aran,  may  be  distinguished  from 
the  normal  follicle  under  menstrual  hypersemia  by  its  position;  it  is 
often  more  or  less  central,  not  peripheral ;  it  does  not  cause  so  marked 
a  projection  on  the  surface  of  the  ovary;  its  walls  are  equally  thick, 
showing  no  evidence  of  absorption  at  any  part  preparatory  to  de- 
hiscence; nor  is  there  any  ihcrease  of  vascularity  as  in  a  follicle  pre- 
paring for  dehiscence;  it  does  not  exhibit  the  corpus  luteum  or  the 
corrugated  foldings  of  the  normal  ovisac;  its  contents  are  generally  a 
collection  of  dark  coffee-grounds  matter,  resulting  from  admixture  of 
decomposing  blood-corpuscles,  fragments  of  membrana  granulosa,  inter- 
mixed with  a  dirty  fluid. 

An  inflamed  ovary  seldom  exceeds  twice  its  ordinary  size. 

There  are  many  examples  in  medicine  of  treatment  becoming  an  ele- 
ment in  diagnosis.  But  the  conclusions  drawn  in  this  manner  are 
sometimes  fallacious.  Thus  it  is  frequently  observed  that  ovarian  pain 
and  other  symptoms  taken  to  indicate  oophoritis  are  cured  by  cauteriz- 
ing the  OS  and  cervix  uteri,  which  may  at  the  same  time  exhibit  marks 
of  disease.  It  seems  rational  to  infer  that  the  ovarian  symptoms  were 
only  symptomatic,  or  dependent  upon  the  affection  of  the  uterus;  and 
in  the  majority  of  cases  this,  I  believe,  is  true.  But  it  is  also  true  that 
the  treatment  applied  to  the  uterus  may  really  have  cured  ovarian  dis- 
ease, first,  by  acting  on  the  principle  of  derivation  or  counter-irritation, 
and  secondly,  by  removing  uterine  disease,  which  was  the  source  of 
disease  in  the  ovary. 

Symptoms  and  Course. 

The  pain  is  chiefly  .due  to  peritonitis,  which  is  almost  certain  to 
ensue.  Tumefaction  is  so  inconsiderable  in  recent  inflammations  that 
it  can  hardly  be  the  cause  of  marked  subjective  symptoms,  and  it  is  not 
easy  to  measure  it  even  by  physical  examination. 

Menstruation  may  be  suppressed,  or  there  may  be  an  increased  flow. 

In  very  rare  cases  the  affection  proves  fatal  in  a  few  days.  This 
termination  is  due  to  sanious  decomposition  of  the  ovary,  or  to  acute 
perforation  by  an  abscess. 

Where  it  commences  with  unusually  severe  symptoms,  and  particu- 
larly when  it  leads  to  extensive  degenerations  of  the  ovary,  or  causes 


INFLAMMATION.  265 

much  peritoneal  exudation,  it  may  continue  for  weeks  or  months  with 
more  or  less  marked  remissions.  In  other  cases  perfect  intermissions 
occur,  aud  the  paroxysms  are  synchronous  with  the  catamenial  periods. 
In  the  most  favorable  cases,  which  are  also  tlie  most  common,  after  a 
short  time  the  exudative  process  is  arrested,  and  the  exudation  is  either 
removed  by  absorption,  or  undergoes  the  usual  metamorphosis  into  cel- 
lular or  stringy  strata,  which  bind  the  ovaries  to  the  surrounding  struc- 
tures. Sometimes  a  fibrous  condensation  of  the  exudations  takes  place, 
and  dense  capsules  are  formed  round  the  ovary,  leading  to  atrophy  of 
its  tissue.  The  exudations  into  the  follicles  also  lead  to  various  meta- 
morphoses, with  shrivelling  and  atrophy  of  the  aifected  vesicle. 

When  the  course  is  less  favorable,  a  new  morbid  process  starts  from 
the  inflammation,  and  abscesses  and  various  chronic  tumors  of  the 
ovaries  are  developed. 

Professor  Faye'  relates  a  case  of  abscess  in  the  ovary  in  a  pregnant 
Avoman.  She  had  been  delivered  by  forceps.  During  pregnancy  (her 
first)  she  suffered  much  from  vomiting ;  and  towards  the  end  she  had 
a  fixed  pain  in  the  right  side  of  the  abdomen,  and  several  convulsive 
fits.  On  the  night  after  delivery  she  had  severe  pains,  mistaken  for 
after-pains.  Next  day,  the  pains  were  more  bearing-down  in  character ; 
the  abdomen  was  tender  and  tympanitic.  She  died  fifty-three  hours 
after  delivery.  Douglas's  sac  was  found  filled  with  a  thin  purulent 
sanguineous  exudation.  An  abscess  in  the  right  ovary  had  burst ;  the 
remains  of  the  organ  had  changed  into  a  mere  pulpy  detritus.  There 
was  considerable  degeneration  of  the  cortical  substance,  of  the  kidneys, 
and  there  were  many  extravasations  of  blood  under  the  serous  mem- 
brane covering  the  kidneys,  liver,  and  lung. 

Associated  with  abscesses,  although  probably  different  in  origin,  is 
the  case  narrated  by  Dr.  Farre,  "  in  which  the  ovary  was  entirely  re- 
duced to  a  diffluent  pulp  of  a  yellow  or  brownish-green  color,  of  the 
consistence  and  having  somewhat  the  appearance  of  very  soft  putty, 
immiscible  with  water.  Of  this  morbid  condition,  which  may,  how- 
ever, be  cancerous,  I  met  with  a  striking  example  in  a  case  of  sudden 
death  occurring  in  the  seventh  month  of  pregnancy.  Both  ovaries 
were  of  the  size  and  form  of  a  bullock's  kidney,  their  natural  structure 
was  entirely  destroyed,  and  was  replaced  by  the  soft  substance  just  de- 
scribed. The  circumstance  that  both  ovaries  were  thus  affected  renders 
it  evident  that  the  disease  could  not  have  existed  in  any  great  degree 
at  the  time  of  impregnation." 

Most  of  the  recorded  cases  of  large  abscess  holding  from  one  to  twenty 
pints  of  pus,  are  probably  instances  of  suppuration  taking  place  in  the 
cavities  of  ovarian  cysts. 

When,  says  Matthews  Duncan,  suppuration  has  occurred  in  the  ovary 
or  around  it,  it  may  be  easily  made  out  by  the  attendant  phenomena. 
These  are,  increase  of  pain,  sometimes  throbbing,  once  or  twice  daily 
attacks  of  fever,  hectic.  The  feeling  of  fulness  is  supplanted  by  hard- 
ness, which  has  more  or  less  of  a  resistant  character.  But  all  these 
features  may  be  the  expression  of  inflammation  and  suppuration  outside 

1  Schmidt's  "  Jahrbuch,"  1860. 


266  OVARY. 

and  around  the  ovary,  the  condition  of  this  organ  being  concealed  by 
the  surrounding  disorder. 

The  terminations  of  suppuration  or  abscess  of  the  ovary  are  :  1.  The 
ovary  may  burst  into  the  peritoneum,  causing  abdominal  shock,  collapse, 
or  peritonitis ;  2.  Small  perforations  may  take  ]jlace,  exciting  more  cir- 
cumscribed peritonitis,  and  leading  to  plastic  effusions  surrounding  the 
diseased  ovary  ;  3.  Adhesions  may  be  formed  with  the  bladder  or  in- 
testine, and  a  fistulous  communication  be  established,  by  which  the  pus 
may  be  more  or  less  completely  discharged  ;  4.  The  suppurating  ovary, 
being  the  focus  of  a  pelvic  cellulitis  or  peritonitis,  may  terminate  after 
the  manner  of  this  form  of  pelvic  inflammation,  by  discharging  into  the 
rectum,  vagina,  or  externally  above  Poupart's  ligament. 

The  treatment  must  be  conducted  on  the  same  plan  as  that  which  is 
laid  down  for  pelvic  peritonitis  which  has  proceeded  to  suppuration. 
The  exit  of  pus  should  be  favored  when  there  is  distinct  evidence  of 
an  eliminatory  process. 

Chronic  oophoritis  is  characterized  by  a  sensible  deformity  of  the 
affected  ovary  ;  the  surface  is  knobbed,  its  consistence  harder  than  nor- 
mal. This  induration  results  from  the  hypertrophy  of  the  parenchyma, 
which  in  its  turn  proceeds  from  the  transformation  of  the  effused  matter 
into  the  cellular  tissue.  Possibly  also  there  is  thickening  of  the  tunica 
propria.  Henkel  and  Virchow  compare  this  to  the  interstitial  hyper- 
plasia of  other  glands,  for  example,  the  cirrhosis  of  the  liver.  The 
thickened  capsule  prevents  the  external  dehiscence  of  the  vesicles.  The 
ovum  perishes  in  the  effused  blood  in  the  vesicle.  On  several  occasions 
Scanzoni  found  the  sanguineous  effusion  had  taken  place  not  only  in 
the  interior  of  the  vesicles,  but  also  in  their  immediate  neighborhood ; 
it  thus  became  evident  that  the  friability  of  tissue  which  sometimes 
accompanies  chronic  oophoritis  is  an  important  cause  of  what  is  called 
apoplexy  of  the  ovary. 

Chronic  oophoritis  may  succeed  to  the  acute  form ;  it  may  be  a  con- 
tinuation of  oophoritis  of  childbed,  or  it  may  arise  in  a  subacute  man- 
ner. The  causes  will  be  similar  to  those  which  induce  the  acute  in- 
flammation .  It  is  extremely  probable  that  cystic  disease  in  some  cases, 
if  not  in  many,  takes  its  origin  in  a  slow  inflammation  of  the  follicles. 
The  early  stages  of  cystic  disease  are  often  attended  by  intense  pain, 
and  the  other  signs  of  dysootocia. 

The  menstrual  flow  in  the  early  stages  of  the  disease  will  generally 
be  increased  in  quantity  and  protracted  in  duration,  and  irregular  hem- 
orrhagic discharges  may  occur.  At  a  later  period,  when  probably  the 
follicular  structure  has  become  impaired,  diminution  or  suppression  of 
menstruation  may  be  observed.  The  disease  very  often  affects  one 
ovary  only,  so  that  menstruation,  or  rather  ovulation  is  not  necessarily 
always  attended  by  dysmenorrhoeic  phenomena.  Not  seldom,  one  or  two 
periods  may  pass  without  pain.  This  may  be  explained  by  Xegrier's 
theory  of  the  alternate  action  of  the  ovaries.  AVhen  there  is  no  pain, 
the  healthy  ovary  is  at  work.  In  other  cases,  every  period  is  attended 
by  severe  dysmenorrhoea,  and  then  we  may  infer  either  that  both 
ovaries  are  affected,  or  that  the  general  pelvic  hyperremia  of  ovulation 
may  involve  the  healthy  as  well  as  the  inflamed  ovary. 


INFLAMMATION.  267 

Leucorrhoea  frequently  attends,  but  can  hardly  be  regarded  as  symp- 
tomatic, although  the  discharge  may  in  some  measure  be  a  means  of 
unloading  the  engorgement  of  the  ovario-uterine  vessels. 

Impregnation  may  take  place,  since  one  ovary  only  may  be  involved  ; 
and  even  where  both  are  involved,  there  may  still  remain  some  follicles 
in  a  condition  to  bring  forth  healthy  ova.  Sterility,  however,  is  com- 
mon, partly  because  the  ovaries  are  really  disabled  by  obliteration  of  the 
follicles,  or  by  external  adhesions,  and  partly  also  because  pain  forbids 
eifective  intercourse. 

It  may  terminate  in  cure  by  resolution.  But  it  may  undoubtedly 
go  on  to  destroy  the  proper  structure  of  the  organ.  The  vesicles  may 
become  compressed  and  atrophied,  the  result  being  incurable  araenor- 
rhoea  and  sterility. 

It  may  proceed  to  suppuration,  and  then  the  symptoms  described 
under  Abscess  of  the  Ovary  will  be  observed. 

Aran  says  the  great  danger  of  chronic  oophoritis  is  the  constant 
liability  to  peritonitis,  which  may  prove  fatal.  He  says  he  has  never 
seen  peritonitis  supervene  on  chronic  metritis,  whether  parenchymatous 
or  mucous.  I  cannot  indorse  the  latter  statement;  but  certainly  as  a 
general  proposition  Aran  is  right  in  affirming  the  far  greater  risk  of 
peritonitis  attaching  to  chronic  oophoritis. 

It  has  been  said  that  chronic  oophoritis  may  run  on  for  years,  or  for 
any  length  of  time,  without  the  ovary  becoming  fixed  by  adhesions,  and 
without  causing  suppuration  in  the  neighborhood.  That  this  happy 
negation  may  occur  may  be  admitted ;  but  I  think  the  escape  is  excep- 
tional, and  that  the  danger  indicated  by  Aran  is  not  exaggerated  by  him. 
It  is  not  unreasonable  to  suspect  that  many  of  the  cases  relied  upon  as 
evidence  that  chronic  oophoritis  may  persist  for  years  without  inducing 
mischief  beyond  the  ovary  are  examples  of  oophoralgia  without  inflam- 
mation. 

There  is  a  fibroid  degeneration  of  the  ovary  which  is  attended  by 
complete  disappearance  of  the  follicles.  There  is  a  remarkable  speci- 
men of  this  kind  in  St,  Thomas's  Hospital.  Both  ovaries  are  enlarged 
to  twice  or  thrice  the  normal  size ;  they  are  deeply  furrowed  or  con- 
voluted, and  sections  through  their  substance  present  smooth  surfaces. 
This  is  probably  the  consequence  of  chronic  inflammation,  the  contract- 
ing parenchyma  gradually  obliterating  the  follicles. 

Chronic  oophoritis  is  marked  by  dull,  heavy  pain  in  the  seat  of  one 
or  both  ovaries,  more  or  less  constant,  but  aggravated  by  menstruation, 
by  coitus,  by  standing  or  exertion  in  the  upright  position,  sometimes 
by  a  loaded  rectum  or  bladder.  The  pain  radiates  from  the  ovary  as  a 
centre  to  the  bladder  and  surrounding  organs. 

Constitutional  symptoms,  marked  in  some  cases,  attend.  There  is 
some  degree  of  fever,  accompanied  by  hectic,  if  suppuration  have  taken 
place.  Nervous  symptoms,  indicating  exhaustion,  irritability  from 
constant  pain,  will  generally  show  themselves.  But,  except  in  the 
very  early  stages,  when  the  disease  is  likely  to  be  confounded  with 
ordinary  dysootocia,  the  nervous  symptoms  do  not  often  put  on  the 
hysterical  form. 

To  establish  a  diagnosis,  pain,  as  described  above,  must  exist.     And 


268  OVARY. 

besides  ascertaining  this,  we  must  exclude  other  pelvic  diseases.  Where 
the  ovary  only  is  affected,  we  may  by  touch  determine  its  increased 
bulk,  sensitiveness,  and  perhaps  prolapsus. 

Touch,  single  and  bimanual,  vaginal,  rectal  and  recto-abdominal, 
must  be  performed  in  the  same  manner  as  for  the  detection  of  the  acute 
form.  Since  the  inflamed  ovary  is  commonly  enlarged,  and  is  disposed 
to  drop  behind  the  uterus,  it  may  be  felt  in  the  situation  assumed  by 
the  body  of  the  retroflected  uterus.  The  sound  will  lift  up  the  body 
of  the  uterus,  and  the  ovary,  if  adherent  to  it,  as  is  not  unlikely,  will 
be  carried  up  along  with  it.  But  by  a  little  care  the  uterus  may  gen- 
erally be  isolated  from  the  ovary. 

The  Treatment. 

We  must  rely  mainly  upon  rest,  physiological  and  physical,  and 
derivation.  Bromide  of  potassium,  sedatives,  occasionally  leeches  to 
the  iliac  region,  chloroform-blisters  on  the  same  spot,  iodine-painting, 
or  when  pain  is  acute,  fomentations  or  poultices.  A  valuable  means  of 
derivation  may  be  pursued  by  setting  up  a  small  issue  or  eschar  on  the 
vaginal-portion  of  the  uterus  by  potassa  cum  calce.  This  makes  a 
healthy  granulating  surface  which  heals  with  some  cicatricial  contrac- 
tion. If  the  uterus  were  perfectly  healthy  one  would  hesitate  before 
resorting  to  this  remedy ;  but  in  many  cases  there  is  so  much  compli- 
cation of  uterine  disease  as  will  alone  justify  the  application. 

I  have  in  several  cases  seen  great  relief  obtained  by  wearing  a  Hodge- 
pessary.  It  gives  relief  probably  by  maintaining  the  ovary  at  its 
probable  level,  thus  favoring  disgorgement  of  its  vessels,  and  by  favor- 
ing rest  of  the  organ. 


CHAPTER  XXVI  ri. 

OVAET:  TUBERCLE— CANCER— SOLID  TUMOES. 

Tubercle  in  the  Ovary  is  considered  to  be  extremely  rare.  Rokitansky 
knows  but  one  case  of  tuberculization  of  the  ovaries  ;  there  were  round 
yellow  knots  in  the  ovaries,  and  also  tuberculosis  of  the  tubes  and  peri- 
toneum. And  Kiwisch  says  tubercle  is  not  met  with  in  the  ovary ;  he 
has  only  found  some  tubercular  granules  in  the  stroma  in  intense  peri- 
toneal tuberculosis.     There  is,  however,  no  lack  of  examples  of  what 


CANCER.  269 

must  be  presumed  to  be  invasion  of  the  ovaries  by  tubercle.  Possibly 
an  unequivocal  instance  of  tubercle  limited  to  the  ovaries  has  yet  to  be 
demonstrated.  But  tuberculization  of  the  ovaries  in  association  with 
tubercle  elsewhere,  especially  in  the  uterus,  Fallopian  tubes,  and  neigh- 
boring glands,  is  not  rare.  Thus  in  St.  George's  Museum  (No.  XIV,  78) 
is  a  preparation  exhibiting  scrofulous  disease  of  the  uterus,  tubes,  and 
ovaries.  Both  ovaries  were  converted  into  cavities,  and  contained 
remnants  of  a  thick  semi-fluid,  tubercular  matter.  They  were  greatly 
enlarged,  and  their  walls  much  thickened.  There  was  extensive  tuber- 
culization of  the  lungs  and  pleurisy  ;  also  scrofulous  ulceration  of  the 
right  sterno-clavicular  joint. 

No.  XIV,  79,  in  the  same  museum,  is  another  example.  The  uterus, 
tubes,  and  left  ovary  are  involved.  The  left  ovary  was  converted  into 
an  abscess  containing  scrofulous  pus.  The  subject,  a  girl,  aged  eigh- 
teen, died  of  psoas  abscess  and  scrofulous  disease  of  the  medulla  ob- 
longata. 

Some  may  question  the  tubercular  nature  of  the  matter  contained  in 
the  ovaries  of  these  and  similar  specimens;  but  the  probability  that 
the  ovaries  thus  involved  should  be  aifected  by  disease  diflFerent  in 
character  from  that  w^hich  invaded  so  many  other  structures  in  the 
body  is  infinitely  small.  In  the  case  of  cancer  being  diffused  through 
various  structures  and  organs,  the  cancerous  nature  of  similar  disease 
found  in  the  ovary  is  not  questioned. 

Baillie  described  "  scrofulous  ovaria."  "  The  ovaries,"  he  says  "  are 
sometimes  changed  into  a  true  scrofulous  matter,  intermixed  with  cells." 

Dr.  Bristowe  demonstrated  (Path.  Trans.,  vol.  vi)  the  tuberculous 
nature  of  an  ovary,  diseased  in  common  with  the  tubes  and  uterus. 
The  Fallopian  tubes  were  filled  with  soft  tubercular  matter.  The 
cavity  of  the  uterus  was  distended  by  a  mass  about  as  large  as  a  pigeon's 
egg,  of  softish,  opaque,  yellowish-white  cheese-like  tubercle.  The  mu- 
cous membrane  of  the  fundus  was  wholly  deficient,  and  the  subjacent 
muscular  tissue  was  irregularly  destroyed,  the  tubercular  deposit  at 
many  parts  extending  into  the  substance  of  the  muscle.  The  os  and 
cervix  uteri  were  somewhat  congested ;  they  were  otherwise  healthy. 
The  right  ovary  M'^as  healthy.  The  left  ovary  contained  two  masses  of 
tubercular  deposit,  one  about  as  large  as  a  horse-bean,  the  other  as  large 
as  a  Spanish  nut.  The  deposit  exactly  resembled  that  in  the  uterus  and 
tubes.  Bristowe  says  the  same  thing  has  been  satisfactorily  demon- 
strated by  Dr.  Ogle.  Bernutz  and  Goupil  also  describe  an  autopsy,  in 
which,  with  much  other  disease,  including  tubercular  lungs,  they  found 
both  ovaries  containing  crude  tubercles,  just  like  those  met  with  in  the 
testicle. 

The  course  run  by  tubercle  in  the  ovary,  the  disease  in  this  organ 
being  generally  secondary,  and  of  minor  import  than  its  concomitant 
presence  in  the  lungs  or  other  organs,  scarcely  calls  for  independent 
consideration.  Advancing  disease  elsewhere,  and  attendant  exhaustion 
of  the  whole  system,  preclude  the  idea  of  directing  any  special  treatment 
to  the  ovary.  Where,  however,  the  ovary  is  converted  into  a  sac  con- 
taining tuberculous  pus,  it  is  conceivable  that  tliis  may  burst,  and  thus 
precipitate  death,  by  causing  peritonitis. 


270  ^  OVARY. 

Cancer  of  the  Ovary. 

Cancer  resembles  tubercle  in  being  a  diffusive  disease.  More  fre- 
quently than  tubercle  it  is  primary  in  the  ovary.  But,  still,  in  the 
majority  of  cases,  by  the  time  at  least  that  it  attracts  attention  in  the 
living,  and  almost  always  as  it  is  seen  in  the  dead,  cancer  has  invaded 
other  organs  as  well.  It  is  frequently  consecutive  upon  disease  of  the 
uterus  and  the  pelvic  and  abdominal  glands. 

The  secondary  invasion  of  the  ovary  by  cancer  was  accurately  made 
out  in  a  specimen  exhibited  by  Dr.  Bristowe  to  the  Pathological  Society. 
In  this  case  innumerable  cancerous  nodules  were  attached  to  the  peri- 
toneum. There  was  also  an  ovarian  tumor  showing  cancerous  disease. 
The  ovarian  tumor  was  essentially  unilocular.  It  was  originally  an 
ovarian  cystic  tumor,  the  parietes  of  which  had  become  secondarily  in- 
volved in  cancerous  disease  from  its  peritoneal  connection. 

Next  to  cystic  disease,  cancer  is  the  most  frequent  disease  of  the 
ovary.  It  is  often  combined  with  the  cystoid  formation.  Every  form 
of  cancer  may  be  reproduced  in  the  ovary.  It  frequently  appears  as 
medullary  carcinoma,  in  the  form  of  a  distinct  mass,  or  of  a  roundish 
tuberous  tumor  completely  supplanting  the  ovary,  and  growing  to  the 
size  of  a  fist,  or  of  a  child's  head,  or  bigger.  In  some  places  it  resembles, 
in  its  firmness  and  the  preponderance  of  its  framework,  the  fibrous  can- 
cer ;  in  others  it  is  soft,  very  juicy,  fluctuating,  encephaloid.  The  de- 
generated ovary  is  sometimes  free,  but  mostly  united  to  surrounding 
structures  by  adhesion.  In  some  rare  cases,  says  Rokitansky,  carcinoma 
of  the  ovary  arises  from  the  degeneration  of  a  corpus  luteum. 

Often  the  medullary  cancerous  degeneration  is,  in  size  and  form, 
symmetrical.  It  occurs  especially  in  young  persons  as  a  primitive  dis- 
ease. It  is  also  associated  with  cancer  of  the  uterus,  breast,  liver,  peri- 
toneum, stomach,  intestine,  and  lumbar  glands ;  and  appears  as  a  part 
of  a  general  widespread  cancer  formation. 

How  cancer  may  invade  an  ovary  in  the  midst  of  active  function  is 
illustrated  in  a  specimen  (No.  2640)  in  the  College  of  Surgeons.  It 
consists  of  a  uterus,  with  ovaries  and  appendages.  "  There  is  a  well- 
formed  foetus,  of  about  five  months,  with  its  membranes  and  placenta 
within  the  uterus.  The  ovaries  are  both  extensively  diseased — enlarged. 
The  tissue  of  the  left  is  soft,  flocculent,  and  vascular ;  that  of  the  right 
is  replaced  by  a  collection  of  cysts,  most  of  which  are  filled  with  soft, 
laminated,  and  apparently  medullary  substance." 

In  St.  Thomas's  Museum  is  a  similar  specimen  (No.  FF,  51).  Both 
ovaries  are  of  ovoid  shape,  much  nodulated  on  the  surface,  and  not  pre- 
senting in  any  part  the  appearance  or  structure  of  ovary.  They  appear 
to  consist  entirely  of  medullary  (encephaloid)  matter.  The  same  disease 
was  found  in  the  mammse  and  liver.  The  woman  was  five  months 
pregnant  with  a  well-formed  foetus. 

Medullary  cancer  occurs  upon  the  cyst-walls  and  the  cyst-cavities, 
especially  in  the  form  of  villous  cancer.  The  gelatinous  cancer  thus 
appears  in  the  cystoid  growths.  On  the  inside  of  the  cysts,  here  and 
there,  are  seen  flat,  rounded,  medullary  knots ;  or  villous,  cauliflower- 
like excrescences.     Both  grow  from  all  points  of  the  cyst-wall,  until 


CANCER.  271 

they  fill  the  cavity ;  and  at  length  the  growth  may  penetrate  the  wall, 
so  that  the  medullary  carcinoma  grows  free  in  the  peritoneal  cavity, 
seizing  neighboring  structures,  and  the  whole  cystoid-formation  becomes 
fixed  in  all  directions.  This  cysto-carcinoma  also  often  occurs  sym- 
metrically in  both  ovaries — more  commonly  so  in  the  more  mature 
periods  of  life. 

Cancer  of  the  ovary  is  most  frequently  seen  in  the  encephaloid  form. 
It  may  attain  considerable  size,  forming  a  globular  mass,  with  spher- 
oidal knobby  projections.  Courty  relates  a  case  in  which  a  tumor  of 
this  kind,  weighing  about  eleven  pounds,  left  the  corresponding  tube 
quite  unaifectecl,  whilst  there  was  congestive  hypertrophy  of  the  uterus, 
and  return  of  hemorrhages  simulating  the  menses  in  a  woman  who  had 
passed  the  menopause.  The  encephaloid  masses,  diffluent  in  several 
places,  appeared  to  have  arisen  in  the  Graafian  vesicles,  so  encysted 
were  they ;  they  even  seemed,  as  Rokitansky  pointed  out  in  other  cases, 
to  have  sprung  up  on  the  internal  membrane  of  the  vesicle,  preserving 
there  an  areolar  or  alveolar  aspect,  whilst  the  centre  was  filled  with 
liquid,  chiefly  blood.  Several  of  the  cysts  were  distended  with  blood, 
the  result  of  internal  hemorrhage.  In  some  of  the  cysts  some  black 
pigment  was  accumulated  in  the  walls. 

Cancerous  tumors  of  the  ovary  sometimes  come  under  the  category 
of  solid  tumors.  Thus,  the  specimen  (No.  2246^^)  in  Guy's  Museum 
shows  "  both  ovaries  affected  by  carcinoma,  which  has  converted  them 
into  solid  tumors,  about  the  size  of  the  human  kidney.  The  subject, 
aged  40,  was  under  Dr.  Gull  for  carcinoma  of  the  brain,  breasts,  and 
various  other  parts.  She  was  delivered  prematurely  of  a  child  in  hos- 
pital, a  few  weeks  before  her  death." 

"  The  most  remarkable  examples  of  hard  cancers  with  fibrous  tumors 
that  I  have  yet  seen,"  says  Paget,  "  have  been  in  the  ovaries  of  certain 
patients  with  common  hard  cancers  of  the  stomach  or  breast.  In  these 
cases  the  place  of  the  ovary  on  either,  or  on  both  sides,  is  occupied  by 
a  nodulated  mass  of  uniformly  hard,  heavy,  white,  and  fibrous  tissue. 
The  mass  appears  to  be  generally  of  oval  form,  and  may  be  three  or 
more  inches  in  diameter.  Its  toughness  exceeds  that  of  even  the 
firmest  fibrous  tumors,  and  its  component  fibres,  though  too  slender  to 
be  measured,  are  peculiarly  hard,  compact,  closely  and  irregularly 
woven.  With  these  I  have  found  only  few  and  imperfect  cancer-cells, 
with  more  numerous  nuclei,  elongated  and  slender.  They  are  not 
mingled  with  elastic  or  other  '  yellow-element '  fibres." 

The  following  case  (No.  31.76)  in  St.  Bartholomew's  Museum  sug- 
gests how  narrow  is  occasionally  the  line  of  demarcation  between 
malignant  disease  of  the  ovary  and  the  presumed  fibrous  disease  of 
that  organ.  The  specimen  exhibits  the  uterus  and  ovaries :  "  The 
place  of  each  ovary  is  occupied  by  a  large,  hard,  oval  tumor,  nodulated 
on  its  external  surface.  The  tumors  consist  of  a  very  dense  and  hard, 
obscurely  fibrous  tissue  ;  and  upon  the  surface,  as  well  as  in  the  interior 
of  each,  there  are  small  membranous  cysts,  which  contained  a  serous  fluid. 
The  uterus  was  healthy.  The  subject  was  38  years  of  age ;  her  breast 
had  been  removed  three  years  before  for  hard  cancer."     But  for  the 


272  O  Y  A  R  Y. 

histor}^.  the  general  appearance  of  the  ovaries  might  be  taken  for  the 
result  of  fibrous  transformation. 

3Ielanosis  resembles  other  forms  of  malignant  disease  in  its  diffusive 
property.  I  have  not  met  with  example  or- record  of  melanosis  limited 
to  the  ovary.  Like  other  forms  of  malignant  disease,  it  probably 
almost  always  attacks  the  ovary  secondarily.  There  is  a  good  example 
(No.  31.16)  in  St.  Bartholomew's  Museum  :  "The  ovaries  are  altered 
in  form ;  their  natural  structure  is  removed,  and  its  place  occupied  by 
a  very  soft  melanotic  matter.  There  are  also  some  small  circumscribed 
deposits  of  melanotic  matter  in  the  peritoneum  covering  the  uterus. 
Taken  from  a  young  woman  in  whom  melanosis  existed  in  many  other 
organs." 

In  St.  George's  Museum  (XIV,  112)  is  a  specimen  of  "simple  cysts 
in  each  ovary.  The  following  note  is  probably  written  by  Sir  B. 
Brodie :  The  cysts  contained  a  thick,  black,  unctuous  and  nauseous 
substance  of  the  consistence  of  tar.  A  small  polypus  is  attached  to 
the  cervix ;  a  small  ulcer  is  seen  in  the  interior  of  the  fundus.  The 
woman  had  her  knee  amputated  for  fungus  hsematodes  by  Sir  Benjamin 
Brodie,  and  the  disease  of  the  organs  of  generation  Avas  not  known.  Is 
the  color  of  the  ovarian  fluid  owing  to  the  same  substance  as  melanosis  ?" 

In  the  College  of  Surgeons  (No.  2642)  is  a  specimen  of  melanosis 
of  the  ovary.  There  was  similar  disease  over  the  peritoneum,  omentum, 
pleurae,  and  lungs.  The  sternum,  ribs,  cranial  bones,  &c.,  were  black, 
brittle,  unusually  soft.  The  uterus  appeared  healthy.  This  specimen 
came  from  the  museum  of  Robert  Liston.  No.  2642a  is  another  mela- 
notic ovary.  The  disease  involves  the  uterus  and  other  parts.  The 
specimen  was  presented  by  Lawrence. 

The  frequent  transition  from  the  cystic  tumor  to  colloid  cancer  sug- 
gests the  suspicion  that  some  forms  at  least,  esj)ecially  the  proliferous, 
partake  of  the  cancerous  character.  If  this  be  assumed,  then  the  pri- 
mary origin  of  cancer  in  the  ovary  must  be  admitted  to  be  frequent. 
The  history  of  pathological  processes  does  not,  I  believe,  lend  much 
confirmation  to  the  hypothesis  of  the  ready  convertibility  of  one  form 
of  morbid  product  into  another.  For  example,  if  I  may  appeal  to 
my  own  observation,  I  should  say  that  fibroid  tumors  of  the  uterus 
are  not  greatly  more  liable  to  the  invasion  of  cancer  than  is  the  normal 
tissue  of  the  uterus.  Cancer  of  the  uterus  begins  as  cancer,  and  not 
as  any  other  disease.  So  far,  then,  as  analogical  reasoning  may  be 
trusted,  that  which  in  its  advanced  stages  is  obviously  cancer,  in  the 
ovaries,  as  elsewhere,  is  cancer  ah  initio.  That  cancer  of  the  ovary 
preserves,  for  a  comparatively  lengthened  time,  its  exclusive  habitat 
in  the  ovary  before  spreading  to  other  parts,  may  be  explained  by  the 
comparatively  isolated  terminal  position  of  the  ovary. 

Cancer  certainly  appears  to  linger  longer  in  the  ovary  without  con- 
taminating other  parts  tlian  it  does  in  the  uterus.  These  considerations 
must  weigh  greatly  in  favor  of  regarding  the  compound  proliferous 
cysts  of  the  ovary  practically  as  non-malignant,  and  therefore  as  being 
suitable  for  extirpation. 

The  strong  innate  disposition  of  the  ovary  to  develop  cystic  forma- 


TUMORS.  273 

tions  may  deterinine  the  frequent  assumption,  by  the  original  cancerous 
element,  of  the  cystic  or  alveolar  form. 

Cancerous  disease  of  the  ovary,  as  elsewhere,  occurs  more  frequently 
in  middle  life  and  later  life ;  but  it  may  arise  in  childhood. 

When  cancer  has  existed  some  time  in  its  pronounced  forms,  and  es- 
pecially when  the  broad  ligaments  and  glands  of  the  pelvis  and  abdo- 
men are  involved,  ascites  is  a  frequent  complication. 

The  course  of  ovarian  cancer  is  frequently  involved  in  that  of  ma- 
lignant disease  elsewhere ;  but  it  not  uncommonly  takes  the  lead  in 
producing  the  cachexia  and  peritonitis  which  cause  the  fatal  issue. 

The  colloid  cancer  grows  rapidly,  and  to  a  large  size;  but  does  not 
quickly  tend  to  destroy  life  by  contaminating  the  system.  The  oppor- 
tunities of  examining  the  primary  stages  of  its  formation  are  therefore 
rare,  except  in  cases  where  the  affected  ovaries  have  been  removed  by 
operation.  Mr.  Heath  exliibited  to  the  Pathological  Society  (Path. 
Trans.,  vol.  xvi)  a  specimen  of  cancer  of  both  ovaries,  in  which  death 
was  produced  by  obstruction  of  the  bowels. 

The  circumstances  which,  according  to  Dr.  T.  Gaillard  Thomas,  who 
has  written  a  valuable  memoir  on  Malignant  Diseases  of  the  Ovaries,^ 
most  prominently  point  to  the  development  of  the  disease,  are:  "1. 
The  rapid  development  of  a  solid  tumor  in  an  ovary,  with  2.  Marked 
depreciation  of  the  strength,  spirits,  and  general  condition.  3.  The  oc- 
currence of  oedema  pedum  and  spansemia  at  an  early  period,  and  con- 
sequently dependent  upon  a  general  blood  state,  and  not  the  consequence 
of  pressure.  4.  Lancinating  and  burning  pains  through  the  tumor. 
5.  Cachectic  aspect.  6.  The  occurrence  of  ascites  without  evidence  of 
cirrhosis  or  other  hepatic  disease;  organic  disease  of  the  kidneys,  or 
heart,  or  chronic  peritonitis ;  the  fluid  accumulating  in  such  large 
amounts  as  to  force  aside  the  supernatant  intestines,  and  produce  dul- 
ness  in  place  of  resonance  on  percussion  in  dorsal  decubitus." 

These  signs  must,  however,  be  taken  with  some  qualifications. 
OEdema  of  the  legs  and  ascites  are  not  constant,  even  at  stages  when 
the  disease  has  produced  marked  ravages  upon  the  general  system.  I 
have,  moreover,  found  it  in  practice  difficult  to  distinguish  solid  malig- 
nant ovarian  tumors  from  malignant  disease  around  the  caput  coli.  It 
is  not,  indeed,  very  important  in  a  therapeutical  point  of  view  to 
make  the  diagnosis,  since  in  either  case  the  treatment  would  be  the 
same. 

Solid  Tumors  of  the  Ovary. — For  want  of  more  precise  pathological 
materials  for  discrimination,  it  is  convenient  to  group  certain  tumors 
of  the  ovary  under  this  general  term.  On  clinical  grounds  this  dis- 
tinct recognition  of  solid  tumors  of  the  ovary  is  of  great  value.  The 
solid  tumors  include  not  only  fibrous  or  fibro-cystic  tuniors,  but  tuber- 
cular and  malignant  tumors  of  the  ovary.  Solid  tumors  in  the  ovary 
then,  frequently,  are  a  local  expression  of  diffusive  disease  which  in- 
volves other  organs  as  well.  This  consideration  of  the  characters  of 
solid  tumors,  will  strengthen  the  rule  not  to  attempt  the  extirpation  of 
solid  ovarian  tumors.     Of  what  use,  for  example,  would  it  be  to  re- 


'  American  Journal  of  Ub-tctrii'S, 

18 


274  OVARY. 

move  a  cancerous  ovary,  when  it  is  in  the  highest  degree  probable  that 
the  disease  has  extended  to  other  organs  ? 

A.  Fibrous  or  Jibro-muscular  tumors  of  the  ovary  are  so  rare  that 
their  existence  has  been  doubted.  In  some  instances  where  it  has  been 
concluded  that  one  or  both  ovaries  had  been  the  seat  of  fibrous  tumors, 
it  is  reasonable  to  conjecture  that  the  tumors  really  arose  in  the  uterus, 
and,  becoming  pedunculated,  pressed  upon  the  ovaries,  whose  proper 
structures  became  obscured.  At  the  same  time,  since  fibrous  and  non- 
striated  muscular  elements  form  a  natural  constituent  of  the  oxslyj, 
there  is  sound  histological  reason  for  admitting  the  possibility  of  tumors 
being  developed  from  exaggerated  extension  of  these  elements. 

There  is  a  specimen  in  the  London  Hos^jital  Museum  described  by 
Dr.  Ramsbotham  (No.  Ea.  27)  as  "  a  large  fibro-muscular  tumor  pro- 
jecting from  the  fundus  uteri.  The  ovaries  are  as  large  as  a  hen's  egg, 
nodular  surface,  and  converted  into  dense  fibrous  masses." 

Cruveilhier  had  drawn  attention  to  the  fact  that  fibrous  tumors  were 
found  implanted  upon  or  in  the  substance  of  the  ovary,  which  by  their 
structure  could  not  be  distinguished  from  fibroid  tumors  of  the  uterus. 
He  observed  that  they  were  often  found  at  the  same  time  in  both 
organs,  as  in  the  specimen  referred  to  of  Dr.  Ramsbotham.  Dr.  Baillie 
also  was  struck  with  the  identity  of  structure,  and  observed  that  these 
tumors  of  the  ovary  ran  the  same  course,  and  were  liable  to  the  same 
cartilaginous  and  bony  transformations  as  the  fibroids  of  the  uterus. 

In  Guy's  Museum  is  a  specimen  (No.  2246)  consisting  of  uterus  and 
ovaries.  "  The  latter  are  converted  into  large  tumors,  each  the  size  of 
a  cocoauut,  by  the  production  of  a  fibro-plastic  material.  The  stomach 
was  aifected  in  the  same  way  by  a  growth  which  resembled  that  seen 
in  the  recurrent  fibroid  tumors." 

There  is  a  specimen  in  Guy's  Museum  of  both  ovaries  converted  into 
solid  tumors  (No.  2225).  Both  ovaries  are  uniformly  enlarged  to  the 
size  of  one's  fist,  smooth  externally,  and  compact  internally.  The 
growth  is  seen  to  consist  of  fibro-plastic  material,  rather  than  cancerous. 
The  woman  had  borne  children.  The  tumors  commenced  after  cessa- 
tion of  menstruation,  and  caused  a  swelling  above  the  pubes.  The  case 
is  alluded  to  by  Dr.  Bright,  who  says  it  is  difficult  to  determine  whether 
the  tumors  are  malignant  or  scrofulous.  The  tumors  are  quite  smooth 
externally,  and  the  section  exhibits  a  perfectly  homogeneous  appearance. 

Guy's  Museum  also  contains  another  specimen  (No.  2246'''*).  The 
ovaries  are  converted  into  solid  hard  oval  tumors  composed  of  fibro- 
plastic material.  Each  weighed  about  three  pounds.  One  contains 
•three  or  four  cysts.  They  are  smooth  on  the  surface.  The  patient  was 
admitted  for  ovarian  disease,  took  pleurisy,  and  died. 

Scanzoni  says  he  has  known  only  four  cases  in  which  autopsy  verified 
the  fibrous  nature  of  a  tumor  diagnosed  during  life.  The  smallest  was 
the  size  of  a  goose's  egg;  it  was  spherical,  elongated,  hard  as  cartilage, 
and  almost  without  vessels.  The  biggest  had  exceeded  the  size  of  a 
man's  head ;  its  section  showed  a  concentric  disposition  of  its  fibres 
around  several  centres;  its  tissue  was  loose,  inclosing  numerous  vessels, 
and  in  some  places  the  veins  presented  an  organization  resembling  that 
of  the  corpora  cavernosa;  it  weighed  about  twenty  pounds;  it  was  irreg- 


TUMORS.  275 

ular,  as  if  formed  of  several  tumors  compressed  against  each  other. 
There  remained  no  trace  of  the  normal  tissue  of  the  ovary,  and  in  the 
other  ovary  were  several  dropsical  vesicles,  some  as  large  as  a  pigeon's 
egg.     The  patient  had  died  of  Bright's  disease. 

A  specimen  in  St.  George's  Museum  (No.  XIV,  140)  seems  to  offer 
the  clearest  features  of  a  fibrous  tumor  of  the  ovary.  It  is  represented 
in  Fiff.  66.  It  is  described  in  the  catalogue  as  "A  fibrous  tumor  of 
the  ovary  from  a  woman  aged  50,  who  died  of  disease  of  the  heart. 
The  uterus  also  contained  a  fibrous  tumor  in  its  walls."  The  position 
of  the  tumor  in  this  case  in  the  centre  of  the  ovary  excludes  the  objec- 
tion urged  against  other  cases,  that  its  origin  might  be  uterine.  The 
coincidence  of  fibroid  tumor  in  the  uterus  so  often  observed,  points  to  a 
general  disposition  in  the  fibro-muscular  elements  of  the  uterus,  broad 
ligaments,  and  ovaries  to  undergo  like  transformations.  This  tissue,  it 
is  known,  is  intimately  connected  throughout  all  these  organs. 

The  affinity  of  these  tumors  with  fibroids  of  the  uterus  is  illustrated 
by  a  specimen  M'hich  Mr.  Wells  exhibited  (Path.  Trans,  vol.  x)  of  a 
fibrous  tumor  of  the  ovary  found  after  death.  It  was  of  the  size  of  a 
large  cocoanut.  A  section  of  the  tumor  showed  that  it  was  composed 
of  fibrous  tissue,  the  denser  parts  being  calcified  by  a  deposit  of  car- 
bonate of  lime. 

A  specimen  was  exhibited  at  the  Obstetrical  Society  last  year,  which 
was  examined  by  Dr.  Wilson  Fox,  who  described  it  as  a  "  loculated 
fibroid ;  as  having  in  the  more  central  and  transparent  parts  of  the  loculi 
a  great  number  of  non-striated  muscular  fibres."  Mr.  Wells  says  he 
has  seen  only  two  instances.  He  removed  "two  tumors  which  were 
really  fibrous  tumors  of  one  ovary,  the  right  in  both  cases.  One 
weighed  nine  ounces,  the  other  four  pounds  and  a  half.  In  both  cases 
there  was  a  large  quantity  of  fluid  in  the  peritoneal  cavity.  One  pa- 
tient was  in  the  third  month  of  pregnancy.  Both  recovered.  One  of 
these  tumors  is  now  in  the  Museum  of  the  College  of  Surgeons." 

In  St.  Thomas's  Museum  is  a  specimen  (No.  FF,  47)  showing  "  the 
half  of  a  large,  fibrous,  kidney-shaped  tumor  of  the  right  ovary,  with 
the  uterus  attached.  The  entire  tumor  weighed  five  pounds  and  a  half; 
it  is  deeply  fissured  on  its  external  surface ;  and  in  parts,  is  covered  by 
a  false  membrane,  where  it  had  adhered  to  the  abdominal  parietes. 
When  recent,  it  was  highly  vascular,  and  of  fleshy  consistence;  its 
structure  is  throughout  closely  intersected  by  dense  fibrous  bands. 
From  a  woman  aged  22." 

Another  specimen  in  St.  George's  Museum  (XIV,  139)  further  illus- 
trates the  subject.  It  consists  of  the  uterus  and  ovaries.  The  latter 
are  observed  considerably  enlarged,  and  have  undergone  transformation 
into  dense  fibrous  structure ;  a  small  mass  of  calcareous  matter  has  been 
deposited  in  the  left  ovary.  Two  of  the  Nabothian  glands  of  the  cer- 
vix uteri  are  slightly  enlarged.  This  calcareous  degeneration  is  pre- 
sumptive evidence  of  the  fibro-muscular  nature  of  the  tumor. 

In  most  of  the  presumed  fibrous  tumors  the  cystic  cavities  have 
been  the  most  noticeable  features.  The  cysts  may  be  more  or  less  ob- 
literated by  the  hyperplastic  condition  of  their  walls.  These  over- 
grown partitions  are  made  up  of  a  fibrous  vascular  mass,  not  in  any 


276  OVARY. 

way  distinguishable  from  that  usually  seen  in  cyst-walls.  This  kind 
of  fibro-cystic  tumor  grows  very  rapidly,  and  has  a  strong  hemorrhagic 
disposition,  causing  also  in  some  cases  effusion  of  blood  into  the  cyst- 
cavity.  A  specimen  is  thus  described  by  Dr.  Ritchie.  "  On  making 
a  section  through  this,  it  was  found  to  be  invested  on  every  side  by  a 
firm  fibrous  capsule,  about  two  lines  in  thickness.  This  capsule  sent 
projections  into  the  interior  of  the  tumor,  and  these  projections  met  and 
crossed  each  other  at  different  angles,  so  as  to  form  a  network.  From 
the  interstices  of  the  network  projected  a  number  of  thin-walled  trans- 
lucent vesicles,  containing  a  colorless  fluid.  The  largest  did  not  exceed 
the  size  of  a  small  plum,  whilst  the  smallest  were  mere  specks.  Most 
of  the  larger  ones  had  been  forced  into  an  elongated  oval  shape,  and  as 
they  projected  from  the  fibrous  network,  the  latter  formed  a  sort  of  col- 
lar which  embraced  them.  Some  of  the  vesicles  were  very  vascular, 
receiving  little  trunks  of  vessels,  which  run  along  the  fibrous  bands. 
The  vesicles  could  be  enucleated  entire.  They  appeared  to  be  formed 
by  a  basement-membrane,  epitheliated  internally,  and  covered  exter- 
nally with  shreds  of  fibrous  tissue." 

It  appears  then  to  be  highly  probable  that  most  of  the  apparent 
fibrous  tumors  of  the  ovary  differ  from  undoubted  cystic  tumors,  chiefly 
in  the  greater  relative  proportion  of  the  fibrous  walls,  and  the  lesser 
development  of  the  cysts.  Scanzoni's  larger  specimen  referred  to  above 
seems  to  confirm  this  view. 

Dr.  Wilks,  reporting  on  three  tumors  of  the  ovary  exhibited  to  the 
Pathological  Society,^  says,  "  The  specimens  referred  to  afford  examples 
of  the  various  grades  of  disease  which  the  ovaries  may  undergo.  We 
may  see  in  them  the  connection  between  a  hard  fibrous  tumor  and  the 
simple  cystic  disease.  We  may  have  in  the  first  place  a  multilocular 
cystic  disease ;  then  a  similar  disease  with  the  addition  of  solid  fibro- 
cellular  growths  between  the  sacs ;  thirdly,  a  disease  made  up  of  the 
same  parts,  but  where  the  solid  predominates ;  fourthly,  a  uniform 
fibrous  tumor ;  and  lastly,  a  hard  dense  fibrous  growth  resembling  the 
analogous  tumor  in  the  uterus." 

Dr.  Bristowe  and  Mr.  Hutchinson,  who  also  examined  the  specimens, 
confirm  the  opinion  of  Dr.  Wilks,  that  one  of  them  was  of  the  same 
nature  as  ordinary  cystic  ovarian  tumor,  but  that  the  intercystic  or  solid 
tissue  has  been  developed  in  a  far  greater  proportion  than  usual. 

Dr.  Bristowe  and  Mr.  Hutchinson  suggest  that  the  absence  of  mus- 
cular fibres  in  ovarian  tumors  distinguishes  them  from  the  uterine 
tumors.  They  admit  that  large  fibrous  tumors  may  grow  from  the 
ovary. 

B.  Enchondromatous  Tumors. — Kiwisch  says  he  has  observed  two 
examples  of  this  tumor.  In  one,  cartilaginous  concretions  surrounded 
the  ovary  in  the  form  of  numerous  scales  or  rounded  protuberances. 
In  the  other  case  the  right  ovary  was  entirely  transformed  into  a  tumor 
the  size  of  the  fist,  surrounded  with  false  membranes  of  which  the 
external  layers  inclosed  cartilaginous  nodules,  coarse  and  hard,  whilst 
the  interior  of  the  tumor  resembled  a  cartilaginous  mass,  hyaline  and 
of  less  density. 

'   Pathological  Traneactions,  vol.  ix. 


CYSTIC    DISEASE.  277 


CHAPTER  XXIX. 

OVAKIAN  CYSTIC  TUMORS;  THEIR  NATURE— SIMPLE ;  MULTIPLE; 
PROLIFEROUS;  CYSTO-SARCOMATOUS  ;  TUBO-OVARIAN— CON- 
TENTS OF  OVARIAN  CYSTS:  DERMOID  CYSTS. 

Tumors  of  the  ovary  may,  for  clinical  purposes,  in  the  first  place  be 
divided  roughly  into  solid  and  cystic.  The  solid  tumors  have  been 
described  in  the  preceding  chapter.  The  cystic  are  the  most  common, 
and  practically  the  most  important. 

Ovarian  cysts  are  distinguished  by  Paget  as  1.  Simple  or  barren, 
containing  fluid  or  unorganized  matter;  and  2.  Compound  or  proliferous, 
containing  variously  organized  matters.  They  may  further  be  usefully 
distinguished  as  Malignant  or  benign.  All  these  tumors,  on  account  of 
their  glandular  origin,  are  grouped  together  as  adenoid.  In  association 
with  ovarian  cysts  proper  it  is  convenient,  and  even  necessary,  to  study 
certain  extra-ovarian  or  pseudo-ovarian  cysts.  For  example,  there  are 
cysts  which  are  developed  in  the  broad  ligaments,  or  which  are  formed 
in  structures  so  close  to  the  ovaries  that  they  easily  simulate  ovarian 
cysts  in  the  living,  and  are  not  always  easily  distinguished  by  dissection 
in  the  dead.  These  will  be  described  in  the  chapters  devoted  to  the 
Pathology  of  the  Broad  Ligaments,  and  of  the  Fallopian  Tubes. 

1 .  Simple  Ovarian  Cysts. — The  most  simple  idea  of  an  ovarian  cystic 
formation  is  derived  from  the  observation  of  certain  specimens  of  dis- 
tension or  enlargement  of  Graafian  sacs  in  the  early  stage.  By  ex- 
amining, for  example,  such  a  specimen  as  that  represented  in  Fig.  67, 
which  represents  a  section  of  an  ovary  in  St.  Bartholomew's  Museum, 
one  cannot  help  being  struck  with  the  appearance  of  the  cysts  arranged 
in  a  row  close  to  the  free  border  of  the  ovary,  just  as  the  Graafian  sacs 
are  disposed  in  the  normal  ovary.  These  are,  in  fact,  morbidly-dilated 
Graafian  sacs.  In  different  specimens  we  may  see  similar  appearances, 
the  cysts  being  larger  and  larger,  until  their  distinct  existence  is  lost  by 
the  septa  between  them  being  absorbed  by  pressure  and  atrophy. 

That  such  is  the  real  history  and  nature  of  the  ordinary  simple  ovarian 
cyst  is  proved  by  the  following  observations.  1.  The  structure  of  its 
walls  is  identical  with  that  of  the  Graafian  sac.  2.  Rokitansky^  has 
found  ova  in  cysts  of  this  kind ;  and  this  very  interesting,  if  not  crucial 
fact,  was  verified  by  the  late  Dr.  Ritchie,  in  1864,  in  the  ovaries  of  a 
woman  operated  upon  by  Mr.  Spencer  Wells.  Both  tumors  contained 
a  number  of  small  cysts,  which  were  evidently  enlarged  Graafian  fol- 
licles. Mr.  Wells  submitted  the  specimens  to  Dr.  W^oodham  Webb  for 
examination.     Dr.  Webb  reported^  as  follows  :  "  Both  the  tumors  you 

1  Wochenblatt  d   Zeitschrift  d.  kk.  Gesellschaft  d.  Aerzte  zu  Wien,  1855. 

2  Mr.  Spencer  Wells,   ''  Diseases  of  the  Ovaries,"   1872. 


278 


OVARY. 


sent  to  me,  after  their  removal  from  a  woman  54  years  old,  were  growths 
in  excess  of  true  ovarian  structure.  The  multilocular  character  was 
produced  by  clusters  of  ovisacs  of  various  sizes.     Ova,  with  the  other 


Fig.  67. 


Section  of  ovary.     Early  stage  of  cystic  disease.    (Nat.  size.) 

natural  contents,  were  to  be  found  in  all  the  small  sacs.  The  fibrous 
coats  of  the  larger  sacs  were  thickened,  and  had  many  secondary  sacs 
develojDcd  in  them.  The  interior  was  lined  with  epithelium,  which  in 
some  instances  had,  by  parthenogenetic  enlargement  and  successive  bud- 

FiG.  68. 


Outer  surface  of  ovary,  shovring  prominences  of  dilated  Graafian  follicles.    (Xat.  size.)    Same  spec. 

as  Fig.  67. 


dings  of  the  cells,  given  rise  to  bunches  of  grape-like  growths — re- 
peated generations  of  imperfect  ova.  The  whole,  therefore,  was  nothing 
more  than  a  reproduction  in  the  human  subject  of  conditions  which  are 
natural  in  some  of  the  lower  creatures." 

2.  Dr.  Ritchie  further  says  •}  "Since  Augu,st,  1864, 1  have  succeeded 
in  finding  ova  in  a  large  number  of  ovarian  cysts.  Some  of  the  ova 
were  perfect,  with  a  sharply-defined  zona  pellucida,  a  germinal  vesicle, 
and  a  germinal  spot ;  others  were  more  or  less  imperfect,  many  having 
the  appearances  mentioned  by  Rokitansky.  I  have  never  found  an 
ovum  in  a  loculus  larger  than  a  cherry,  and  never  in  a  loculus  which 
contained  jelly-like  contents." 

'  "  Ovarian  Phvsiologv  and  Pathology,"  1865. 


CYSTIC     DISEASE. 


279 


3.  Cystic  disease  of  the  ovary  rarely  begins  except  during  the  period 
of  normal  ovarian  activity.  Cysts  have  indeed  been  found  in  young 
girls,  even  under  ten  ;  but  menstruation  sometimes  is  premature  ;  and 
some  cysts  springing  from  the  broad  ligaments  may  have  been  errone- 
ously regarded  as  ovarian. 

4.  Cysts  are  more  frequent  in  the  ovaries  than  in  any  other  organ  ; 
and  in  many  respects  they  differ  from  the  cysts  seen  elsewhere.     The 


Fig.  69. 


Showing  incipient  cystic  enlargement  of  the  Graafian  follicles  in  both  ovaries. 
(Middlesex  Museum.) 

small  cysts  sometimes  seen  on  the  peritoneal  investment  of  the  ovary 
and  of  the  uterus  are  different  in  nature  from  the  true  ovarian  cyst. 

Although  it  is  frequently  the  case  that  several,  if  not  many  Graafian 
sacs  are  affected  together,  this  is  not  always  so.  Even  in  cases  where 
one  or  more  sacs  have  become  so  large  as  to  have  called  for  removal  by 
abdominal  section,  menstruation  has  continued,  and  portions  of  healthy 
ovary  have  been  found. 

Frequently  the  degeneration  of  the  follicles  is  symmetrical,  both 
ovaries  being  affected  in  a  similar  manner  as  in  the  specimen  figured 
(Fig.  69)  in  the  Middlesex  Hospital. 

There  is  an  excellent  "  Hunterian"  preparation  in  the  College  of  Sur- 
geons (No.  2616),  showing  incipient  ovarian  cystic  disease.  It  is  "an 
enlarged  ovary,  in  the  interior  of  which  are  numerous  small  oval, 
smooth-walled  cysts,  with  distinct  thin  walls,  all  probably  enlarged 
Graafian  vesicles." 

Up  to  a  certain  point  several  follicles  may  enlarge  wdth  tolerable 
uniformity,  as  in  Figs.  67,  69.  But  after  a  while,  one  generally  takes 
precedence  of  the  rest,  and  growing  more  rapidly  compresses  them,  so 


280  OYAEY. 

that  they  either  remain  small,  or  their  walls  becoming  atrophied  and 
thinned  under  the  compression  of  their  nutrient  vessels,  the  cysts 
hitherto  distinct  are  fused  into  one.  By  a  kind  of  natural  selection 
one  obtains  predominance,  absorbing  the  others,  or  destroying  them. 
Sometimes  portions  of  the  minor  cysts  remain  in  the  form  of  projecting 
processes,  constituting  chambers  or  loculi,  communicating  with  the  large 
cyst.  In  this  way  what  are  called  multiple  cysts  are  formed.  They  are 
really  simple  in  their  nature.  Although  multiple  in  number,  they  are 
nothing  but  agglomerations  of  simple  cysts,  and  do  not,  collectively 
any  more  than  singly,  possess  the  distinctive  property  of  the  compound 
or  proliferous  cyst,  that  of  self-multiplication  by  endogenous  gemma- 
tion. 

In  some  cases  there  appears  to  be  one,  or  chiefly  one,  follicle  affected, 
and  when  this  happens  this  follicle  may  be  found  not  at  the  periphery 
of  the  ovary,  but  deeply  imbedded  in  the  stroma.  In  these  cases  it  is 
reasonable  to  surmise  that  the  ovum  was  prevented  by  the  thickness  of 
the  surrounding  structure  from  making  its  way  to  the  surface  at  the 
proper  time ;  that  the  effort  would  result  in  distension  of  the  sac,  the 
outpouring  of  an  excessive  quantity  of  blood  into  it ;  and  hence,  if  the 
epithelial  lining  retained,  as  it  is  likely  to  do,  its  proliferous  virtue, 
the  gradual  formation  of  a  cystic  tumor.  In  University  College  Mu- 
seum (T  f )  is  a  good  specimen  of  hemorrhage  into  the  ov^ary.  In  Guy's 
Museum  is  another  specimen  (No.  2231^"),  showing  "  an  ovary  much 
distended,  having  been  filled  with  blood."     (See  Fig.  65.) 

Dysmenorrhoea  is  in  my  experience  a  frequent  antecedent  of  ovarian 
dropsy,  when  this  disease  begins  during  the  period  of  ovarian  function. 
This  observation  corroborates  the  opinion  that  some  obstruction  to  the 
due  maturation  and  escape  of  ova  is  one  cause.  It  has  often  been  con- 
jectured that  a  single  life,  by  suppressing  one  ovario-uterine  function, 
led  to  abnormal  action  of  the  formative-force.  Out  of  Mr.  Spencer 
Wells's  500  cases,  221  were  unmarried  and  18  were  widows.  On  the 
other  hand,  the  complication  of  ovarian  dropsy  with  pregnancy  is  not 
very  uncommon. 

What  is  the  beginning  of  this  transformation  of  the  Graafian  folli- 
cles ?  The  formative-force  is  peculiarly  active  in  the  ovary.  If  inter- 
rupted or  hindered  in  its  ordinary  progress,  it  may  be  supposed  that, 
still  persisting,  it  will  reveal  itself  in  abnormal  results.  In  University 
College  Museum  (No.  866)  is  an  interesting  specimen,  which  may  serve 
to  illustrate  the  effect  of  obstruction  to  the  healthy  course  of  menstrua- 
tion. It  exhibits  cysts  in  the  ovaries  and  tubes,  and  a  fibroid  tumor  of 
the  uterus  inside,  which  probably  obstructed  the  uterine  openings  of  the 
tubes.  Rigby  says  he  traced  in  one  case  an  ovarian  dropsy  from  its 
beginning  in  oophoritis.  Scanzoni  says  there  is  no  doubt  that  dropsy 
of  the  Graafian  follicles  is  sometimes  caused  in  this  way  :  the  menstrual 
congestions  in  the  ovaries  do  not  attain  sufficient  intensity  to  effect  the 
bursting  of  the  follicular  wall,  and  the  result  is  that  an  increase  of 
secretion  and  its  accumulation  in  the  cavity  thus  takes  place.  The 
follicular  wall  is  thus  gradually  hypertrophied,  and  by  the  formation 
of  new  vessels  causes  a  permanently  increased  secretion.  The  com])ara- 
tively  great  frequency  of  these  follicular  dropsies  in  women  who  have 


CYSTIC     DISEASE.  281 

long  suffered  from  chlorosis  or  other  diseases,  combined  with  amenor- 
rhoea,  speaks  in  favor  of  this  view. 

The  principal  varieties  of  the  complex  or  'proliferous  ovainan  cysts 
have  been  described,  as  Paget  truly  says,  "to  the  very  life"  by  Dr. 
Hodgkin,  to  whom  we  are  indebted  for  the  first  knowledge  of  their  true 
pathology.  Hodgkin  divides  them  into  two  principal  or  extreme  forms 
of  endogenous  cysts :  namely,  those  which  are  broad-based  and  spher- 
oidal, imitating  more  or  less  the  characters  of  the  parent  cyst,  and  those 
that  are  pedunculated,  clustered,  and  thin-walled.  Between  these  forms 
many  transitional  and  mixed  forms  may  be  found.  A  typical  example 
of  the  first  is  in  the  Museum  of  the  College  of  Surgeons  (figured  p.  417, 
Paget).  It  is  a  large  cyst,  with  tough,  compact,  and  laminated  walls, 
polished  on  both  their  surfaces.  On  its  inner  surface  there  project,  with 
broad  bases,  many  smaller  cysts,  of  various  sizes  and  variously  grouped 
and  accumulated.  These  nearly  fill  the  cavity  of  the  parent  cyst ;  many 
of  them  are  globular ;  many  deviate  from  the  globular  form  through 
mutual  compression ;  and  within  many  of  them  are  similar  but  more 
thickly-walled  cysts  of  a  third  order. 

Respecting  tlie  mode  of  generation  of  the  endogenous  cysts,  they 
appear  to  be  derived  from  cell-germs,  developed  in  the  parent  cyst- 
walls,  and  thence,  as  they  grow  into  secondary  cysts,  projecting  into  the 
parent  cavity ;  or  disparting  the  mid-layers  of  the  walls,  and  remaining 
quite  inclosed  between  them ;  or  more  rarely  growing  outwards,  and 
projecting  into  the  cavity  of  the  peritoneum. 

Dr.  Wilson  Fox^  says,  "  All  the  forms  of  cysts  met  with  in  the  ovary 
originate  from  the  Graafian  follicles,  and  that  the  multilocular  forms 
are  not  the  result  of  any  special  degenerations  of  the  stroma  of  the  ovary, 
but  are  due  to  secondary  formations  from  the  interior  of  parent  cysts 
thus  formed."  He  divides  them  into  three  classes.  The  first  and  most 
frequent  manner  in  which  secondary  cysts  are  formed  is  the  result  of 
the  production  of  a  series  of  glandular  structures,  presenting  a  tubular 
type,  on  the  inner  wall  of  the  parent  cyst.  Dr.  Fox  describes  the  mode 
of  formation  of  these  glands  as  differing  from  those  of  other  glands, 
which  for  the  most  part  originate  in  the  embryo  as  diverticula  from 
surfaces.  The  process  in  this  case  commences  with  a  stratification  of 
the  epithelium,  into  which  project  papillae  formed  of  the  stroma  of  the 
wall  of  the  parent  cyst,  each  papilla  carrying  a  delicate  vascular  loop. 
Villi  more  or  less  densely  clustered  are  thus  formed,  which  may  persist 
as  such,  and  these,  according  to  Wilks,  Friedreich,  and  Luschka,  may 
become  covered  with  ciliated  epithelium ;  but  in  a  large  number  of  cases 
they  become  converted  into  tubular  structures  of  the  upward  growth  of 
the  stroma  around  their  bases.  Cysts  may  be  formed  while  they  are 
thus  situated  on  the  surface,  from  the  occlusion  of  their  orifices  by  mu- 
tual pressure ;  but  most  commonly  the  growth  of  the  stroma,  by  which 
this  tubular  character  was  first  determined,  continues  until  they  are 
completely  imbedded  in  the  wall  and  covered  by  a  fresh  layer  of  the 
stroma,  the  surface  of  which  may  again  become  the  seat  of  a  new  and 
similar  growth  of  glands  and  villi.     Masses  of  glands  thus  imbedded 


Medico-Chirurgieal  Transactions,  1864. 


282 


OVARY. 


are  dilated  into  cysts  by  their  own  secretion,  and  from  the  semi-solid 
masses  which  project  into  the  interior  of  the  parent  cysts,  and  in  them 
similar  processes  may  be  repeated  indefinitely.  Dr.  Fox  believes  that 
he  has  traced  in  the  variations  between  the  relative  growths  of  the 
stroma  and  these  glands,  which  Mr.  Wells  described  as  "  fibro-epithe- 
lioma,"  or  "alveolar  adenoid  tumor,"  the  source  of  those  varieties  in 
the  density  of  these  masses  which  have  given  rise  to  the  names  of 
"  alveolar  disease  of  the  ovary,"  or  "  cysto-sarcoma  of  the  ovary." 

The  histology  of  these  tumors  is  well  illustrated  in  Figs.  70,  71,  for 
which  I  am  indebted  to  Mr.  Henry  Arnott. 

Fig.  70  represents  three  thin  sections  from  the  solid  stromal  portions 
of  a  multilocular  cystic  tumor,  removed  by  Mr.  Croft,  in  jN'ovember, 
1872.  The  specimens  were  fresh  and  stained  with  carmine.  All  show 
varieties  of  developing  fibrous  tissue. 

a.  Dense  connective  tissue,  studded  with  irregular  rod-shaped 
nuclei ;  the  outlines  of  the  cells  not  discernible. 

b.  Delicate  connective  tissue,  with  slender  cells  at  rare  intervals. 

c.  Rapidly-growing  connective  tissue,  rich  in  nuclei,  plump  and 
oval,  which  can  be  seen  here  and  there,  to  be  contained  in  lai'ge  spindle- 
cells. 


Fibrous  stroma  or  compound  cystic  tumor  of  ovary. — (By  H.  Arnott.) 


Fig.  71  shows  epithelium  from  the  inside  of  the  same  compound 
cystic  tumor. 

a.  Detached  flakes  of  columnar  epithelium,  viewed  sideways. 

6.  Part  of  a  large  surface  of  epithelium,  lining  a  small  cyst ;  showing 
the  polygonal  aspect  of  the  columnar  cells  as  seen  from  above,  and 


CYSTIC    TUMORS. 


283 


showing,  besides,  dilatation   of  the  wall,  in  which  the  cells  appear 
swollen  and  partly  out  of  focus,  rendering  their  nuclei  less  distinct. 

Cysto-sarcoma  of  the  ovary. — Miiller  applied  this  name  to  those 
tumors  in  which  the  fibrous  iiitercystic  substance  equals  or  exceeds  in 
quantity  the  contained  fluid.  However,  all  degrees  may  be  observed 
in  different  tumors,  and  we  cannot  therefore  venture  to  separate  ab- 
ruptly ovarian  cystic  tumors  into  diflFerent  classes.  Good  typical  ex- 
amples of  all  of  them— a,  the  simple;  b,  the  simple  but  multiple  cyst; 
c,  the  proliferous  or  compound  cyst ;  d,  the  proliferous  or  compound 
cyst,  with  colloid  contents ;  e,  the  proliferous,  with  large  sarcomatous 
formation — may  frequently  be  met  with;  but  in  a  large  majority  of 
instances,  ovarian  tumors  share  the  characters  of  two  or  more  of  these 
varieties.  The  more  active  the  proliferous  tendency,  the  further  the 
departure  from  simplicity  of  organization,  the  more  nearly  does  that 
tumor  approach  in  its  relations  to  malignancy.  Whether,  however, 
any  form  of  ovarian  tumor,  excepting  the  fungoid  (medullary)  is  truly 
cancerous  in  its  tendencies,  is  a  matter  of  much  doubt;  and  practically 
all  must  be  treated  as  if  it  were  proved  that  they  are  not  so,  unless 
they  are  solid.     Brodie  called  these  sero-cystic  sarcomata. 


Fig.  71. 


X    220 


Epithelial  lining  of  a  compound  ovarian  cyst. — (H.  Arnott.) 

Alveolar  or  colloid  tumor  of  the  ovary  is  a  not  infrequent  form  of 
the  compound  cyst.  It  contains  very  numerous  loculi,  which  are  filled 
with  a  semi-solid  tenacious  substance  resembling  gum.  It,  however, 
often  complicates  tumors  in  which  many  cysts  contain  fluid,  and  which 
resemble  those  of  the  common  compound  form.  There  is  much  reason 
to  doubt  whether  the  usual  tendencies  of  true  cancer  are  ever  mani- 
fested by  it. 


284 


OVARY. 


Fig.  72,  taken  from  a  specimen  in  University  College  Museum,  pre- 
pared by  i)r.  Fox,  exhibits  a  section  of  the  colloid  or  alveolar  tumor. 


Fig.  72. 


Univ.  Coll.  Mus.,  No.  5054  (from  nat.  half-size.) 
Section  of  an  ovarian  tumor  showing  the  alveolar  structure. 


Fig.  73,  also  from  a  preparation  in  University  College  Museum, 
exhibits  a  form  of  proliferous  cyst.  Both  ovaries  are  affected.  In 
one  the  cyst  is  perforated  by  a  dendritic  proliferation.  By  eccentric 
pressure,  the  result  of  endogenous  growth,  the  capsule  of  the  ovary 
has  given  way,  so  that  the  dendritic  processes  project  on  the  surface. 

Tubo-ovarian  Cysts. — Adolphe  Richard^  first  described  a  form  of  cyst, 
into  the  composition  of  which  both  the  Fallopian  tube  and  the  ovary 
entered.  He  detailed  five  observations,  and  cited  analogous  cases  from 
Morgagni,  Frank,  Chambon,  Boivin  and  Duges,  Kiwisch,  and  others. 
He  demonstrated  that  ovarian  cysts  may  open  into  the  uterus  by  the 
tubes ;  that  after  having  received  the  fluid  of  the  cyst,  the  tube  con- 
tinues to  undergo  a  pathological  action,  by  which  its  calibre  in- 
creases, its  length  being  doubled,  its  walls  thickened,  the  folds  of  its 
mucous  membrane  smootlied  out ;  that  lastly,  the  dilatation  extending 
gradually  to  the  internal  part  of  the  oviduct,  the  communication  be- 
tween the  canal  of  the  dilated  tube  and  the  cyst  remains,  and  there  is 
thus  made  up  a  cavity  or  cyst  compounded  of  dilated  tube  and  the 
ovarian  cyst. 

My  former  colleague  at  the  Western  General  Dispensary,  Mr.  An- 
derson, described  a  clear  case  of  tubo-ovarian  cyst.  A  woman  who  was 
waiting  to  be  tapped  began  to  pass  an  excessive  quantity  of  urine,  and 

1  Memoires  de  la  Society  de  Cliiniririe,  1856. 


CYSTS. 


285 


her  distress  subsided.  The  fluid  passed  was  albuinenized  serum,  with 
cholesterin  plates.  After  six  months  the  woman  died  from  a  sudden 
outburst  of  haemoptysis.  A  large  empty  cyst  was  found  lying,  col- 
lapsed and  loose,  in  the  belly  ;  it  had  thick  walls,  and  included  some 
lesser  cysts.     A  good-sized  staff  passed  with  the  greatest  facility  from 


Univ.  Coll.  Mus.  (from  nat.  two-thirds  size.) 

Both  ovaries  affected  with  proliferating  malignant  disease.    Dendritic  processes  perforatinQ 

the  investing  structures. 


the  cyst  along  one  of  the  Fallopian  tubes  into  the  uterus  and  vagina. 
The  supposed  urine  did  not  come  from  the  bladder,  but  was  cystic  fluid 
which  escaped  by  the  tube,  uterus,  and  vagina. 

Boinet  relates  a  case  interesting  in  its  bearing  on  this  subject,  A 
young  married  lady,  some  months  after  her  last  labor,  and  after  exces- 
sive excitations,  felt  acute  pain  in  the  ovary,  simulating  local  peritonitis. 
The  ovary  swelled  considerably,  and  soon  became  as  big  as  a  fist ;  all. 
the  signs  of  acute  ovaritis  of  the  most  intense  degree  existed,  and 
Boinet  feared  rupture  of  the  ovary,  or  the  formation  of  an  abscess  in 
the  iliac  fossa.  She  had  fever,  shiverings,  vomiting ;  a  fatal  issue  was 
apprehended.  Something  burst,  and  there  escaped  by  the  vagina  a 
quart  of  watery  fluid,  albuminous.  The  symptoms  subsided  ;  but  for 
three  years  afterwards,  fluid  of  the  nature  described  escaped  from  the 
vagina. 

It  is  conjectured  that  in  this  case  a  Graafian  follicle  burst  into  the 
adherent  tube. 

We  may  conclude  then,  that  tubo-ovarian  cysts  may  be  formed : 
1.  By  the  establishment  of  a  communication  between  an  ovarian  cyst 
and  the  Fallopian  tube,  the  outer  end  of  which  dilates  to  form  one 


286 


OVAEY, 


cavity  with  the  opened  ovarian  cyst ;  2.  By  the  bursting  of  a  Graafian 
follicle,  diseased  or  healthy,  under  circumstances  which  provoke  peri- 
tonitis and  the  formation  of  adhesions  uniting  the  fimbriated  extremity 
of  the  tube  to  the  ovary,  the  communication  with  the  Graafian  sac 
being  maintained  or  not ;  3.  It  is  possible  that  a  tubo-ovarian  cyst 
may  be  formed  in  a  different  way  from  the  two  preceding.  The  tube 
may  be  distended  from  carrjdng  pus  or  irritating  matter,  and  set  up 
inflammation,  which  gives  rise  to  plastic  eifusions  binding  the  fimbri- 
ated extremity  to  the  surface  of  the  ovary.  Most  frequently  the 
matter  escapes  into  the  peritoneal  cavity,  and  the  peritonitis  is  widely 
diifused  ;  but  it  may  be  wholly  or  in  great  part  surrounded  by  the 
rapid  throwing  out  of  plastic  matter,  which  forms  a  cyst  of  the  kind 
described.  It  is  possible  that  the  cysts  represented  in  the  annexed 
drawing  (see  Fig.  74)  from  Carswell's  Pathological  Anatomy  are  of 
this  kind. 


(Half-size.) — Carswell. 
a.  Uterus,    h.  Fallopian  tubes,    d.  Tubo-ovariau  cyst. 


The  characteristic  of  these  cases  is  their  rapid  formation  under  symp- 
toms of  ovaritis  or  peritonitis  following  upon  sudden  escape  of  ovarian 
fluid  by  the  vagina,  where  there  had  previously  existed  a  tumor,  or 
symptoms  of  acute  ovaritis  or  peritonitis  with  rapidly-forming  swelling. 

CysU  from  Development  of  ivandering  Ova. — That  ova  impregnated, 
and  especially  non-impregnated,  occasionally  fall  into  the  abdominal 
cavity,  not  being  caught  by  the  Fallopian  tube,  there  is  every  reason 
to  believe.  When  discussing  the  pathology  of  retro-uterine  heemato- 
cele,  and  of  extra-uterine  gestation,  this  accident  will  be  again  referred 
to.  In  this  place  it  is  only  necessary  to  refer  to  an  hypothesis  of 
Boinet,  that  ova  which  have  gone  astray  in  this  manner  may  give  rise 
to  cystic  growths  :  "  May  not,"  he  asks,  "  that  happen  for  the  forma- 
tion of  cysts  of  the  ovary,  which  happens  for  fecundated  vesicles  ? 
These  are  sometimes  developed  in  the  ovary  itself,  or  in  the  Fallopian 
tube,  or  in  the  peritoneum,  constituting  abnormal  gestations.  May  it 
not,  then,  liappen  that  the  non-fecundated  ovum,  diseased  through 
causes  referred  to,  may  be  pathologically  developed  either  in  the  ovary 


CYSTS.  287 

where  it  remains  fixed,  or  in  the  tnbe  wliich  it  has  reached,  as  at  the 
moment  of  fecundation,  or  lastly  in  the  peritoneum,  into  which  it  has 
fallen  f 

Contentu  of  Ovarian  Cysts. 

In  the  following  condensed  sketch  of  the  contents  of  ovarian  cysts, 
I  borrow  freely  from  the  more  minute  accounts  given  by  Scherer  and 
Mr.  Wells. 

Beginning  with  the  normal  Graafian  vesicle,  as  a  point  of  departure, 
we  find  it  to  contain  a  minute  quantity  of  a  slightly  viscid,  whitish- 
yellow  albuminous  fluid  resembling  the  serum  of  blood.  It  is  alkaline, 
of  pale  whitish-yellow  color,  and  transparent.  It  is  not  ropy  nor 
viscid,  but  limpid,  readily  separating  into  minute  drops.  It  contains 
a  small  quantity  of  a  substance  which  Avill  coagulate  with  alchohol,  or 
when  exposed  to  a  raised  temperature.  It  holds  in  suspension  spher- 
oidal, nucleated  epithelial  cells,  and  shreds  of  epithelium  from  the 
membrana  granulosa  of  the  ovisac. 

Under  certain  pathological  conditions,  by  which  either  the  Graafian 
follicles  enlarge  or  new  cavities  are  formed,  the  contained  fluids  are 
altered,  and  may  conveniently  be  arranged  into  three  groups,  according 
as  they  resemble  the  normal  fluid  of  the  ovisac,  or  as  they  become 
more  or  less  ropy  and  viscid,  or  as  in  consistence  they  resemble  mucus. 
The  fluids  of  the  two  last  groups  are  frequently  met  with  in  multi- 
locular  cysts,  and  in  the  alveolar  and  colloid  tumors. 

The  contents  of  the  simple  cysts  consist  commonly  of  a  clear,  limpid, 
pale-citron  or  straw-colored  fluid,  which  flows  in  a  stream  as  readily 
as  blood-serum,  or  even  more  so.  Scherer  demonstrated  the  presence 
of  paralbumen  and  metalbumen,  as  albuminates  peculiar  to  ovarian 
fluids.  Fibrinogen  is  also  a  constituent,  and  may  be  demonstrated  by 
applving  Dr.  A.  Schmidt's  test,  which  is  the  addition  of  a  few  drops 
of  blood  to  the  fluid,  when  a  distinct  clot  will  form  in  from  twenty -five 
to  ninety  minutes,  involving  the  blood-corpuscles  which  had  been 
added.  The  clot  is  generally  so  firm  that  it  can  be  raised  unbroken, 
and  if  squeezed  in  the  hand  a  quantity  of  fluid  issues,  leaving  a  loose 
Ijundle  of  fibrillated  substance.  Cholesterin  crystals  are  sometimes 
seen  in  the  fluid  of  simple  cysts,  and  may  be  detected  by  their  glisten- 
ing in  the  stream  as  it  flows  through  a  canula  in  tapping.  After 
standing  a  while,  these  crystals  form  a  pellicle  on  the  surface  of  the 
fluid.     Scales  of  epithelium  are  almost  always  found  floating  in  it. 

It  must  not,  however,  be  assumed  that  even  in  simple  cysts  the  fluid 
is  always  clear.  Pus  or  blood  is  occasionally  found  ;  and  pus  is  occa- 
sionally apt  to  be  found  on  a  second  or  subsequent  tapping,  although 
the  flaid  drawn  by  the  first  tapping  was  perfectly  clear.  Admixture 
of  pus  and  blood  will  aflect  the  color  variously,  according  to  the  period 
and  quantity  of  the  eifusion.  Thus  it  may  be  yellow,  green,  brown- 
ish, or  red.  The  turbidity  of  the  fluid  generally  depends  upon  the 
admixture  of  these  secondary  matters. 

The  greatest  variety  of  contents,  however,  is  found  in  the  compound 
cysts.  It  is  no  uncommon  thing  to  find  clear  thin  fluid  in  one  cyst, 
turbid  greenish  or  brownish  fluid  in  another,  purulent  matter  in  a 


288  OVARY. 

third,  and  colloid  or  gelatinous  or  syrupy  tenacious  matter  in  other 
cysts.  When  a  compound  cyst  has  once  been  tapped,  as  it  refills  the 
contents  are  pretty  sure  to  alter  in  character,  becoming  mixed  with  pus 
and  blood.  Mr.  Wells  observes  that  the  more  consistent  colloid  sub- 
stances are  occasionally  distributed  in  a  very  peculiar  manner.  They 
form  conical  columns,  with  their  broad  bases  directed  out-wards.  Be- 
tween these  almost  isolated  columns  a  whitish  or  yellowish-white  mat- 
ter, consisting  of  epithelial  cells  in  a  state  of  degeneration,  is  placed 
without  any  definite  arrangement.  Such  cysts  have  probably  been 
formed  by  the  confluence  of  smaller  cysts,  of  which  nothing  remained 
but  the  epithelial  investment,  undergoing  fatty  decay,  and  so  tracing 
out  the  former  lines  of  separation. 

The  chemical  and  microscopical  characters  of  ovarian  fluids  have 
been  elaborately  described  by  Eichwald.'  The  first  group  oi  abnormal 
fluids,  very  liquid^  are  generally  found  in  molecular  cysts  with  a  smooth 
internal  surface  invested  with  a  layer  of  pavement-epithelium.  Their 
specific  gravity  ranges  from  1003  to  1006.  They  have  no  odor,  and 
are  either  neutral  or  slightly  alkaline.  The  following  analysis  repre- 
sents the  average  composition : 

Water, 98'2.5 

Minrral  suits  (sulphates,  chlorates,  pliosphates),    .  ll^.O 

Organic  salts  (lactates),          .....  4.0 
Chcilesterin,  occasionally  traces. 

Alhuniinose,  ........  1.5 


1000.0 


These  fluids  are  devoid  of  fat  and  albumen. 

In  the  clear  slightly  ropy  fluid  of  some  of  the  small  cysts  in  the 
broad  ligament,  minute  flakes  are  occasionally  found.  They  are 
granular,  with  a  minute  round  or  irregular  cumulus  of  fatty  granules 
in  the  centre. 

The  Second  Group  of  Liquid  but  Ropy  Ovarian  Fluids. — They  are  of 
the  consistence  of  oil  or  syrup,  and  frothing  when  shaken.  They  are 
clear  amber  or  lemon-colored,  or  pinkish  like  the  peritoneal  fluid.  The 
reddish  fluids,  after  standing,  deposit  the  red  blood-corpuscles  to  which 
they  owe  their  color.  These  fluids  may  become  turbid,  and  of  gray- 
ish, yellowish-green  or  whitish  color,  from  the  presence  of  cells  and  oil- 
globules,  which  they  hold  in  suspension.  Their  reaction  is  alkaline; 
specific  gravity,  1009  to  1018.  Heat,  alcohol,  and  nitric  acid  will 
coagulate  them  like  blood  or  ascitic  fluid.  Baedeker,  Thudichum,  and 
others  have  found  leucin.  In  the  fluid  will  generally  be  found  epi- 
thelial cells,  principally  the  pavement-epithelium,  which  lines  the 
cavity  of  the  cysts.  Besides  these,  there  will  be  always  white  blood- 
corpuscles,  sometimes  red  blood-corpuscles,  due  to  capillary  hemor- 
rhage from  the  inner  surface  of  the  cyst.  The  fluid  in  very  old 
cysts  becomes  thicker,  and  assumes  the  consistence  and  color  of  cofl'ee- 
grounds.  It  will  also  contain  granules  of  htematosin  from  disinte- 
grated blood-corpuscles.' 

^  Wiirzburg  ^Mediziiiische  Zeitschrift,  18(34. 


CYSTS.  289 

Third  Group —  Viscid  and  Ropy  Fluids. — These  fluids  or  substances 
are  generally  clear,  colorless,  or  of  a  grayish  tint,  and  semi-transpar- 
ent. They  are  viscid,  adhesive,  resembling  the  vitreous  humor  of  the 
eye,  or  are  jelly-like,  breaking  up  into  lumps.  They  will  not  pass,  or 
only  with  difficulty,  through  a  canula.  They  are  alkaline  or  neutral; 
specific  gravity  1010  to  1015 :  in  colloid  cysts  it  is  as  high  as  1040  or 
more.  They  coagulate  when  exposed  to  high  temperature,  just  like 
the  white  of  egg,  to  which  they  sometimes  bear  a  great  resemblance. 
The  variations  depend  upon  the  conditions  of  the  principal  components, 
the  colloid  bodies  and  the  mucus,  and  the  intermediate  stages  of  meta- 
morphosis from  one  to  the  other.  Epithelial  cells  and  blood-globules 
are  also  found.  They  contain  certain  quantities  of  mineral  salts,  crys- 
tals, or  crystallizable  principles  of  organic  origin,  as  fats,  and  certain 
principles  nearly  allied  to  alkaloids,  viz.,  urea,  creatin,  leucin,  crea- 
tinin,  &e. 

The  microscopical  analysis  shows  fat-granules  and  globules,  large 
colorless  colloid  globules,  with  delicate  margins  and  a  large  transparent 
centre,  either  perfectly  homogeneous,  or  dotted  with  fine  black  spots. 
Some  colloid  globules  inclose  one  or  more  granulated  aggregations. 
There  may  also  be  found  a  large  quantity  of  small  circular  corpuscles, 
clear,  with  a  dark  margin,  containing  a  varying  number  of  fine  dark 
molecules,  and  sometimes,  also,  several  larger  granules  of  high  refract- 
ing power.  They  appear  to  be  identical  with  the  pyoid  bodies  of  Le- 
bert,  or  the  exudative  cells  of  Henle.  Cholesterin  crystals  are  found  in 
great  quantities.  Pigment,  of  dark  brown,  reddish-black,  or  black 
color  in  granules  of  different  sizes,  is  found. 

The  Structure  of  the  Alveolar  or  Traheculated  Framework  of  Cystic 
Tumors. — The  walls  of  the  alveoli,  near  the  base  of  the  tumor,  con- 
sist mostly  of  an  areolar  tissue,  interwoven  with  elastic  fibres.  The 
stroma  will  be  found  undergoing  a  retrograde  transformation  in  various 
stages  of  fatty  metamorphosis.  The  majority  of  the  alveoli  are  lined 
with  a  columnar  or  pavement-epithelium.  The  epithelial  lining  is 
generally  covered  with  a  layer  of  semi-opaque  matter,  consisting  of 
exfoliated  cells,  colloid  globules,  granulated  cells,  horn  cells,  or  pyoid 
bodies. 

The  trabeculse  of  the  alveolar  stroma  consist  of  areolar  tissue  in 
various  stages  of  development.  The  intercellular  substance  of  the 
trabeculse  possesses  the  chemical  properties  of  mucin;  when  treated 
with  acetic  acid  it  coagulates  into  threads.  In  some  portions  of  the 
denser  stroma  alveoli  may  be  found  occasionally,  the  walls  of  which 
consist  of  fasciculi  of  genuine  fibrous  tissue.  Some  of  the  alveoli  are 
so  densely  filled  with  cells  that  intercellular  substances  can  scarcely  be 
discovered ;  others  may  be  found  entirely  devoid  of  cells.  They  con- 
tain instead  a  mucous  substance,  rendered  more  distinct  by  the  addition 
of  water,  which  makes  it  contract.  It  coagulates  into  membranous 
threads  when  treated  with  acetic  acid,  and  dissolves  in  alkalies. 

The  inner  surface  of  the  walls  of  alveoli  of  considerable  size  is  in- 
vested with  a  layer  of  epithelium,  Avhicli  gives  the  character  of  true 
cysts. 

In  large  colloid  cysts  fatty  decay  is  a  very  common  occurrence,  and 

19 


290  OVARY. 

portions  of  the  walls  and  septa  are  destroyed.  It  presents  itself  to  the 
nal?ed  eye  in  irregular  patches  of  dirty  brown  or  yellow  color,  bordered 
by  the  raised  edges  of  the  surrounding  healthy  tissue.  They  are  brittle, 
and  easily  broken  up.  The  lining  epithelium  has  also  undergone  fatty 
metamorphosis.  These  changes  are  due  to  the  compression  and  obliter- 
ation of  the  capillary  vessels.  In  some  cases  these  vessels  may  be 
traced  filled  with  a  brown  finely-granulated  substance.  Hemorrhage 
frequently  takes  place  from  such  partially-destroyed  vessels. 

The  contents  of  the  alveoli  are  mixed  with  and  suspended  in  a  semi- 
fluid medium,  consisting  principally  of  modified  mucin,  which  seldom 
contains  albumen  coagulated  by  heat,  free  albumen  or  septon,  but  oc- 
casionally traces  of  albuminate  of  soda.  It  is  a  thick  creamy  fluid,  of 
greenish-white  color,  not  unlike  the  sputa  in  chronic  bronchitis.  Its 
reaction  is  alkaline. 


CHAPTER  XXX. 

CUTANEOUS  PKOLIFEEOUS  CYSTS;  OE,  DEEMOID  CYSTS  OF  THE 

OVAEY. 

Lebert  gives  the  name  of  "dermoid  cysts"  to  those  structures, 
either  in  newly-formed  or  in  pre-existing  spaces,  which  show  on  the 
inner  surface  of  a  sac,  new  formations,  whose  identity  with  the  struc- 
tures of  the  skin  is  unmistakable,  as  bone,  cartilage,  teeth,  and  hair. 

The  walls  are  generally  very  thick.  The  inner  surface  is  either 
smooth,  or  in  places  there  are  prominences.  The  superficial  layer  of 
the  inner  surface  consists  of  thick  layers  of  pavement-epithelium. 
Indeed",  elements  representing  all  those  of  skin  are  found.  Hair,  fat- 
glands,  sweat-glands,  are  recognizable;  so  that  along  with  hair  we  find 
the  contents  of  the  cyst  to  be  a  yellowish,  fatty  unguent,  made  up  of 
free  fat,  cast-off"  pavement  epithelial  cells,  and  cholesterin  crystals,  which 
sometimes  distinctly  glisten.  The  general  likeness  of  the  interior  of  the 
cysts  to  skin  had  been  often  noticed.     Kohlrausch  demonstrated  it. 

It  was  at  one  time  thought  that  these  dermoid  cysts  were  the  result 
of  an  incomplete  fructification  of  an  ovum.  But  Baillie  found  them 
in  children  wlio  had  never  menstruated ;  and  anatomists  now  gener- 
ally agree  that  they  are  quite  independent  of  conception. 

Brain-matter  has  been  discovered  in  cysts  of  this  kind  by  Gray, 
Chalice,  Friedreichs,  and  Rokitansky.    Friedrciclis  even  found  recently- 


DERMOID     CYSTS. 


291 


formed  strong  cords  of  broad  nervous  branches,  and  unipolar  and  bipolar 
pigmented  ganglionic  cells.  Virchow  has  seen  a  similar  case ;  and  the 
same  pathologist  has  also  described  muscular  fibres.  Bone  is  sometimes 
developed.  It  is  found  in  small  scales  or  lamellae  in  the  areolar  tissues 
beneath  the  skin-formation.  These,  as  they  grow  larger,  acquire  the 
most  extraordinary  shapes,  with  branches  and  spiculse.  The  osseous 
structure  itself  is  that  of  genuine  bone,  the  Haversian  canals  and  bone- 
cells  being  arranged  in  lamellae. 

There  is  little  doubt  that  in  the  living  body  the  fat  often  exists  in 
the  fluid  state.  Thus  there  is  a  specimen  in  Guy's  Museum  (No.  2237-") 
which,  when  opened,  poured  forth  fluid  fat,  which  immediately  solidi- 
fied. In  another  specimen  (No.  2235)  the  fat  was  wholly  soluble  in 
ether.  The  hairs  were  imbedded  in  the  usual  way  in  the  sheaths ;  and 
abundant,  large,  well-formed  sebaceous  follicles  opened  into  the  hair- 
tubes.     The  source  of  the  fat  in  these  cvsts  is  therefore  clear. 


A  dermoid  cyst  of  the  ovary. 
From  specimen  in  St.  Thomas's  Hospital  Museum.    (Half-size.) 

Mr.  Wood  exhibited  a  tumor  removed  from  the  body  of  an  old 
woman,  which  contained  hairs,  and  fat,  no  doubt  fluid  during  life,  as 
it  melted  readily  on  being  exposed  to  heat  equal  to  that  of  the  body. 
(Path.  Trans.,  vol.  x.)  Dr.  Hare  mentioned  another  case  where  solid 
fat  was  found  in  an  ovarian  cyst  after  death,  but  which  melted  at  85°. 
(Path.  Trans.,  vol.  iv.) 

Dr.  Ramsbotham  (Path.  Trans.,  vol.  iv)  describes  a  case  of  labor 
obstructed  by  a  tumor  in  Douglas's  space.  The  tumor  was  punctured 
by  a  long  trocar  through  the  vagina;  a  large  teacupful  of  thick,  yel- 
lowish matter,  like  thick  custard,  ^yas  collected ;  it  became  solid  when 
cool,  and  consisted  of  fat-globules.  As  shown  in  tubes  it  looked  like 
butter.  The  tumor  before  puncture  felt  quite  solid,  no  doubt  from 
tension.     Two  cases,  quoted  from  Ingleby,  gave  the  same  characters. 


292  OVAEY. 

Hence,  Rarasbotham  says,  every  tumor  impeding  labor  should  be  punc- 
tured.    His  patient  recovered. 

They  do  not  grow  exclusively  in  the  ovaries.  There  are  two  kinds. 
Those  which  grow  in  the  ovaries,  which  are  the  most  frequent;  and 
those  which  grow  in  other  parts.  Both  kinds,  says  Paget,  may  be 
regarded  as  diseases  of  the  same  general  group  with  the  cutaneous  pro- 
liferous cysts.  The  great  formative  power  which  they  manifest  is  con- 
sistent with  their  occurring  only  in  embryonic  life,  and  in  the  ovaries, 
in  which,  even  independently  of  impregnation,  one  discovers  so  many 
signs  of  great  capacity  of  development. 

This  active  formative  power  is  remarkably  illustrated  in  the  follow- 
ing case,  presented  to  the  Pathological  Society  (Path.  Trans.,  vol.  viii) 
by  the  late  Mr.  Moore.  The  abdomen  was  larger  than  at  full  period 
of  gestation.  An  opening  formed  near  the  navel,  and  discharged  pus. 
The  opening  was  enlarged  by  incision,  and  about  seven  pounds  of  stuff 
like  putty  was  removed.  Vomiting  came  on,  and  the  patient  died. 
There  was  one  vast  cyst  adherent  at  every  part  of  its  surface,  except 
near  the  bladder.  The  wall  was  tough,  in  part  cretaceous.  It  contained 
hair,  adherent  and  loose,  and  perfectly-formed  teeth.  The  right  ovary 
and  tube  were  a  little  enlarged.  Uterus  healthy,  but  elongated.  Left 
ovary  not  discovered.  Among  the  peritoneal  adhesions  were  many 
small  cysts,  some  of  which  were  attached  by  slender  pedicles  to  the 
main  cyst,  whilst  others  were  entirely  unconnected  with  it,  but  like  it 
contained  soft,  cheesy,  yellow  epithelium,  mixed  with  hairs. 

These  cysts  were  either  formed  from  the  principal  ovarian  cysts, 
or  they  sprang  up  in  the  places  in  which  they  were  found.  Either 
the  cysts,  now  separate,  were  once  parts  of  the  primary  cysts,  and 
loosening  themselves  by  the  lengthening,  and  then  by  the  rupture, 
of  their  pedicles,  they  started  in  independent  life ;  or,  though  formed 
in  the  wall  of  the  main  cyst,  they  were  cast  loose  at  their  first  extru- 
sion from  it. 

Now,  an  inspection  of  the  interior  of  the  large  cyst  shows  that  sec- 
ondary, or  rather  smaller,  cysts  had  burst  into  it.  Others,  likewise, 
may  have  burst  outwards  into  the  peritoneum,  and  forming  adhesions, 
nourished  themselves  at  the  expense  of  the  adhesions  in  which  they 
were  lodged. 

These  tumors  are  often  the  seat  of  inflammation ;  and  by  ulceration 
or  wasting  of  their  walls,  communications  are  established  either  with 
the  exterior  through  the  abdominal  walls,  or  with  the  internal  hollow 
viscera ;  and  hair,  fat,  and  bones  being  discharged,  give  rise  to  the 
suspicion  of  an  extra-uterine  gestation. 

Dr.  Gibbes^  relates  a  remarkable  case,  in  which  labor  being  termina- 
ted by  the  forceps  on  account  of  syncope,  the  patient  was  harassed  by 
the  most  intractable  after-pains.  A  tumor  was  discovered  above  and 
behind  the  pubes,  distinct  from  the  uterus,  and  movable.  On  a  sub- 
sequent day  this  tumor  was  felt  per  vagi  nam  in  the  anterioi'  cul-de-sac. 
It  then  increased  rapidly  to  the  size  of  the  largest  shaddock  ;  and  it  was 
considered  necessary  to  remove  it.  This  was  done,  as  by  the  operation 
for  ovariotomy.     It  grew  from  the  left  broad  ligament.     About  three 

1  Amer.  Journ.  of  Med  Sc,  1869. 


DERMOID     CYSTS.  293 

inches  of  the  Fallopian  tube  were  included  in  the  ligature.  The  cyst 
contained  pus  and  a  mass  of  tine  black  hair.  Menstruation  occurred  at 
several  successive  monthly  periods  through  the  wound.  The  patient 
ultimately  recovered. 

When  these  cysts  are  of  ovarian  origin  the  symptoms  they  produce 
are  generally  similar  to  those  which  attend  other  ovarian  growths. 
They  spring  from  the  same  seat;  they  extend  in  a  similar  manner. 
But  they  differ  in  several  respects.  Their  rate  of  growth  is  usually 
much  slower.  They  often  date  from  an  earlier  age.  They  are  mostly 
more  solid  and  irregular  in  shape.  Fluctuation  is  rarely  so  distinct  or 
diffused ;  this  symptom  indeed  is  not  often  developed,  except  as  the 
result  of  suppuration.  Dermoid  cysts  rarely  attain  so  large  a  size  as 
the  dropsical  tumors  do.  They  more  commonly  terminate  by  setting 
up  inflammation  between  some  part  of  their  walls  and  neighboring 
structures,  and  in  this  way  effect  communications  with  the  hollow 
organs,  as  the  intestinal  canal,  or  the  bladder,  or  else  they  form  fistulous 
openings  externally  through  the  abdominal  wall.  In  all  these  respects 
they  more  resemble  the  abdominal  cases  of  extra-uterine  gestation. 
For  these  indeed  they  are  often  mistaken.  If  foetal  bones  are  discharged, 
it  may  be  concluded  that  the  case  is  one  of  extra-uterine  gestation. 

It  is  rare,  however,  that  this  formation  of  fistulous  outlets  is  attended 
by  a  cure.  It  is  undoubtedly  an  attempt  at  elimination,  but  one  which 
is  only  partially  successful.  The  attempt  is  towards  the  surface;  the 
wall  of  the  tumor  forms  adhesions  with  the  abdominal  wall;  inflamma- 
tion attacks  the  skin,  an  erysipelatous  blush  appears;  the  skin  is  thick- 
ened, tender ;  fluctuation  appears  ;  an  abscess  points  and  bursts,  if  it  be 
not  opened  by  the  surgeon.  The  elected  seat  is  generally  near  the  um- 
bilicus on  one  side.  Nothing  but  pus  may  be  discharged  ;  the  swelling 
undergoes  little  diminution ;  suppuration  goes  on ;  the  signs  of  hectic 
or  irritative  fever  set  in.  Sometimes  masses  of  hair,  matted  together, 
and  quantities  of  fatty  matter,  may  be  present  and  be  dragged  out  from 
the  opening.  This  may  go  on  for  a  long  time,  emaciation  proceeding, 
and  exhaustion  ending  in  death.  Teeth  usually  remain  adhering  to  the 
w^alls  of  the  cyst. 

When  these  tumors  form  a  communication  with  the  bowel  or  bladder, 
the  course  of  events  is  similar.  Pus,  mingled  wdth  hair,  escapes  from 
time  to  time,  producing  attacks  of  severe  pain. 

When  these  cysts  form  a  communication  with  the  bladder,  as  they 
not  infrequently  do,  the  most  puzzling  symptoms  are  apt  to  arise. 
Dysuria  may  harass  the  patient  for  years  ;  generally  cystitis  supervenes, 
and  sometimes  attacks  of  retention  of  urine  occur.  When  fatty  matter 
or  hairs  make  their  escape,  the  diagnosis  is  pretty  clear,  especially  if  a 
tumor  be  observed  in  one  or  other  groin  or  at  the  pelvic  brim.  The 
cyst  occasionally  relieves  itself  partially  at  intervals,  and  then  may  be 
felt  to  diminish  in  size.  The  symptoms  set  up  may  be  so  severe,  either 
by  threatening  life  by  acute  inflammation  or  by  obstruction  to  the  blad- 
der, or  by  exhaustion  from  irritative  fever,  that  an  operation  for  removal 
of  the  tumor  may  be  indicated.  The  operation  for  extirpation  must  be 
conducted  on  the  same  principle  as  that  for  extirpating  ordinary  cystic 


294  OVARIAN    TUMORS. 

tumors  of  the  ovary.  But  to  relieve  the  bladder  it  may  sometimes  be 
enough  to  dilate  the  urethra,  and  bring  away  the  offending  matters. 

That  their  course  is  sometimes  slow,  that  their  developmental  .power 
may  be  very  languid  or  suspended,  is  proved  by  their  being  occasionally 
found  of  moderate  size  on  making  autopsies  in  persons  who  have  died 
of  independent  diseases,  their  existence  during  life  having  been  unsus- 
pected. 

In  a  considerable  proportion  of  cases  the  termination  seems  to  be 
accelerated  by  pregnancy  and  labor.  The  pressure  of  the  gravid  uterus 
and  of  the  child  during  labor  probably  injures  the  cyst,  and  disj^oses  it 
to  inflammation. 

These  tumors  are  exceedingly  apt  to  contract  intimate  adhesions  with 
the  viscera  amongst  which  they  are  imbedded. 

Treatmoit. — When  there  is  evidence  by  pointing  of  working  towards 
the  surface,  it  is  wise  to  open  the  abscess  by  a  bistoury.  This  should 
be  done  cautiously,  to  a  limited  extent,  in  the  first  instance.  The  in- 
cision may  be  subsequently  extended,  perhaps  crucially,  and  the  cavity 
of  the  cyst  explored  by  sound  and  finger.  In  this  way  we  may  facili- 
tate the  evacuation  of  the  contents ;  masses  of  hair  may  be  seized  by 
forceps.  The  cavity  may  be  washed  out  with  Condy's  fluid,  or  weak 
carbolic  acid.  Generally  a  fistulous  opening  remains  for  an  indefinite 
time,  leading  to  hectic  fever.  It  is  therefore  desirable  to  make  tentative 
incisions  with  a  view  to  extirpation.  The  adhesions  they  are  so  apt  to 
contract  will,  however,  often  frustrate  the  attempt.  It  might  be  justi- 
fiable to  lightly  cauterize  the  inner  surface  of  the  cyst  with  the  galvanic 
cautery,  to  modify  its  character.  It  is  scarcely  probable  that  much 
inflammation  would  be  excited  in  surrounding  healthy  structures,  and 
when  the  sloughs  had  been  discharged,  the  cyst  M'ould  contract  and  the 
fistulous  opening  close. 


CHAPTER  XXXI. 

NATURAL  COURSE  AND  TERMINATIONS  OF  OVARIAN  TUMORS. 

The  terminations  of  ovarian  cystic  tumors  are  various ;  but  the 
progress  is  generally  towards  a  fatal  issue. 

1.  They  tend  to  go  on  growing  by  accumulation  of  fluid  until  the 
distension  is  too  great  to  be  borne.  The  cyst  pressing  in  all  directions, 
and  not  al)le  to  extend  backwards  or  much  into  the  pelvis,  stretches 
the  abdominal  walls  in  front,  and  the  diaphragm  above,  driving  the 
intestines  backwards  and  even  encroaching  upon  the  cavity  of  the  chest. 


COURSE.  295 

The  circulation  is  impeded  by  the  pressure  upon  the  aorta  and  vena 
cava.  The  functions  of  the  viscera,  abdominal  and  thoracic,  are  im- 
peded by  pressure.  The  viscera  undergo  a  degree  of  shrinking  or 
atrophy.  Nutrition  and  respiration  and  circulation  being  imperfect, 
in  the  end  exhaustion  ensues. 

In  cases  of  long  standing,  some  amount  of  compensation  is  effected 
by  dilatation  of  the  superficial  veins  of  the  abdomen.  Sometimes,  but 
by  no  means  commonly,  relief  is  sought  by  serous  effusion  in  the  legs. 
More  or  less  oedematous  thickening  of  the  integuments  of  the  lower 
abdomen,  where  the  overhanging  of  the  tumor  is  greatest,  is  not  infre- 
quent. Probably  the  effusion  into  the  cyst  itself  acts  as  an  accom- 
modating process. 

2.  Sometimes  death  occurs  rapidly  or  suddenly  from  asphyxia,  owing 
to  the  pressure  upon  the  heart  and  lungs.  Mr.  R.  F.  Battye  relates  a 
case  of  this  kind  in  a  girl  aged  13.     (Obstr.  Trans.,  vol.  ii.) 

3.  As  Dr.  Bright  says,  some  state  of  unexpected  collapse,  for  which 
no  reason  can  be  assigned,  takes  place,  and  the  jaatient  sinks.  I  have 
seen  several  such  instances.  One  lately  occurred  at  St.  Thomas's.  A 
young  woman  w^as  admitted  with  a  large  ovarian  cyst  which  had  formed 
rapidly.  Tapping  was  contemplated,  but  before  it  w^as  performed, 
death  took  place  almost  suddenly  under  symptoms  of  lung  distress.  It 
was  conjectured  that  rupture  of  the  cyst  might  have  taken  place;  but 
the  cyst  w^as  found  so  universally  adherent  that  there  was  no  spot 
whence  effusion  could  take  place.  The  diaphragm  was  driven  up  so 
as  to  confine  the  heart  and  lungs  within  the  narrowest  space.  The 
lower  lobes  of  the  lungs  were  so  compressed  that  they  presented  a  foli- 
aceous  appearance,  resembling  the  atelectasis  of  new-born  infants.  In 
this  way  a  considerable  portion  of  the  lungs  was  disabled.  I  concluded 
that  under  the  impetus  of  some  excitement  or  exertion,  the  heart  and 
lungs  were  suddenly  taxed  beyond  their  feeble  powers  of  adaptation, 
and  that  thus  asphyxia  was  induced.  In  these  cases  of  very  large 
tumors  there  is  not  only  encroachment  upon  the  space  naturally  per- 
taining to  the  thoracic  organs,  but  the  chest-walls  are  nearly  fixed. 
The  proper  respiratory  movements  are  restricted,  so  that  on  any  sudden 
impetus  to  the  circulation  or  respiration,  the  balance  is  destroyed  and 
asphyxia  results. 

4.  The  cyst  being  free  from  adhesions,  and  tolerably  firm,  may  roll 
over  on  its  axis.  This  may  happen  from  the  enlargement  of  the  uterus 
tilting  it  over,  or  from  overexertion,  when  one  part  of  the  tumor  being 
more  pressed  upon  than  the  opposite  part,  it  rolls  over.  The  effect  of 
this  axial  twdsting  is  to  strangulate  the  pedicle ;  the  bloodvessels  can- 
not return  the  blood  from  the  tumor,  so  congestion  and  bursting  of 
the  vessels  follow.  Hemorrhage  into  the  cyst,  leading  to  sudden  dis- 
tension, causes  shock  and  anaemia  sufficient  to  cause  death,  without 
rupture  of  the  cyst  and  hemorrhage  into  the  peritoneum,  which  may, 
however,  also  happen. 

Should  the  patient  escape  the  more  immediate  danger  of  death  from 
shock,  hemorrhage,  and  peritonitis,  the  strangulation  of  the  tumor  is 
almost  sure  to  lead  to  gangrene. 

But  when  the  strangulation  takes  place  very  gradually,  or  when  the 


296  OVARIAN    TUMORS. 

tumor  is  not  very  vascular,  atrophy  taking  place  slowly,  and  the 
pedicle  being  constantly  stretched,  complete  separation  has  taken  place, 
the  tumor  becoming  loose ;  or  the  tumor  may  shrink  without  being 
detached. 

I  have  related  two  cases  of  this  axial  twisting  in  St.  Thomas's  Hos- 
pital Reports,  1870.  In  one  case  the  rotation  was  caused  by  the 
growth  of  a  gravid  uterus ;  in  the  other  there  was  no  pregnancy,  and 
the  rotation  was  in  all  probability  caused  by  severe  bodily  exertion. 
Dr.  St.  John  Edwards  of  Malta  relates  a  case  (Lancet,  1861).  The 
subject  had  gone  through  one  labor  M'ithout  mishap,  notwithstanding 
the  complication  with  a  movable  ovarian  tumor ;  in  a  second  preg- 
nancy labor  supervened  at  the  seventh  month,  collapse  and  death 
ensued ;  the  tumor  was  found  twisted  and  strangulated.  Mr.  Lawson 
Tait  relates  another  case.  Dr.  Kidd  (Dub.  Quart.  Journal,  1870) 
relates  one  in  a  non-pregnant  girl.  On  this  subject  much  valuable  in- 
formation may  be  gathered  from  a  memoir  by  Rokitansky  (Allg. 
Wiener.  Med.  Wochenschr.,  1870).  He  describes  many  dissections 
which  show:  1.  Atrophy  and  twisting  of  a  Fallopian  tube,  through 
the  dragging  of  its  ovary,  as  by  an  ovarian  fatty  cyst  or  serous  cyst, 
which  in  its  growth  may  pull,  stretch,  and  rend  the  attached  tube. 
2.  Tearing  asunder  of  a  tube  through  the  dragging  of  pseudo-mem- 
branous adhesions,  as  through  adhesion  of  the  right  tube  to  the  small 
intestines.  3.  Tearing  asunder  of  a  tube  or  corresponding  ovary,  as 
w^hen  the  tube  and  ovary  adhere  in  the  recto-vaginal  space ;  the  tear- 
ing being  caused  by  the  uterus  enlarging  in  repeated  pregnancies.  4. 
Axial  twisting.  Professor  Turner  also  has  contributed  a  valuable 
memoir  "  On  Separation  and  Transplantation  of  the  Ovary  due  to 
Atrophy  of  the  Broad  Ligament  and  Fallopian  Tube."  (Edin.  Med. 
and  Surg.  Journ.,  1861.) 

But  twisting  of  the  pedicle  may  lead  to  a  more  happy  result.  The 
compressed  vessels  supplying  no  nutriment  to  the  tumor,  atrophy  and 
shrivelling  may  take  place,  and  thus  a  spontaneous  cure.  The  remains 
of  such  tumors  have  been  found  sometimes  in  Douglas's  pouch  as  a 
hard,  solid,  partly  cartilaginous  substance. 

5.  Simple  dragging  of  the  stalk  may  lead  to  the  same  results  as 
twisting.  This  dragging  may  occur  from  a  growing  uterus  pushing 
the  tumor  up ;  from  adhesions  being  formed,  fixing  the  ovary  in  the 
pelvis,  when  the  growing  uterus  will  drag  out  the  ligament ;  or  the 
ovary  has  contracted  adhesions  higher  up,  so  that  when  the  uterus  re- 
treats again  to  the  pelvis,  the  ligaments  are  stretched.  (Klob,  Roki- 
tansky.) 

6.  It  is  probable  that  some  cystoids  of  the  ovary  .undergo  a  kind  of 
atrophic  involution,  which  may  be  regarded  as  a  spontaneous  cure.  In 
old  women  the  ovaries  are  sometimes  found  as  agglomerates  of  smaller 
or  larger  degenerated  cysts,  seated  in  an  extremely  hard  thick  stroma. 
On  tlieir  inner  surface  are  seen  papillary  outgrowths,  likewise  converted 
into  hard  knots.  Such  formations,  says  Rokitansky,  must  be  regarded 
as  involved  shrunken  cystoids. 

7.  Small  tumors  getting  into  Douglas's  si)ace  may  push  the  uterus 
forward  ujion  the  bladder  so  as  even  to  cause  retention  of  urine.     In 


COURSE.  297 

the  case  of  large  tumors,  the  neck  of  the  bladder  is  sometimes  pulled 
up  along  with  the  uterus,  so  that  the  control  of  the  sphincter  is  im- 
paired. Hence  enuresis.  This  trouble  is  also  created  at  times  by  the 
pressure  of  a  large  tumor  downwards  upon  the  bladder.  Bladder  dis- 
tress is  even  more  likely  to  arise  when  the  tumor  is  the  centre  of  a  mass 
of  adhesions  impeding  the  mobility  of  the  pelvic  organs.  Cystitis  and 
uraemia  may  even  be  induced,  and  thus  cause  death.  Or  the  tumor 
may  so  press  upon  the  kidneys  and  ureters,  as  in  a  case  told  by  Wells, 
that  the  kidneys  may  be  almost  obliterated,  and  thus  produce  ursemia. 

8.  In  like  manner  ovarian  tumors  may  encroach  upon  the  rectum, 
causing  at  times  obstruction  to  the  passage  of  fseces. 

A  fatal  case  of  obstruction  of  the  rectum  by  an  enlarged  ovary  is  re- 
lated by  Dr.  Parker  (Ed.  Med.  Journ.,  1863). 

Dr,  Parker's  patient  suffered  periods  of  constipation  prolonged  to 
several  weeks.  A  dense  tumor  occupied  the  space  between  the  vagina 
and  rectum,  almost  filling  up  the  upper  two-thirds  of  the  pelvis.  It 
could  not  be  dislodged.  The  gum-elastic  catheter  could  not  be  passed 
beyond  the  mass  to  the  promontory  of  the  sacrum.  Fluctuation  was 
detected  in  the  mass,  and  projecting  cysts  were  tapped  per  vaginam. 
A  few  ounces  of  fluid  escaped.  The  patient  ultimately  died  from  the 
effect  of  the  disease. 

9.  Another  mode  in  which  ovarian  tumor  may  cause  rapid  death  is 
by  ileus.  Vomiting,  perhaps  of  stercoraceous  matter,  and  the  other 
symptoms  of  intestinal  obstruction,  come  on  and  carry  off  the  patient. 
On  examination  after  death  no  adhesions  or  other  obvious  cause  of  con- 
striction of  the  intestinal  canal  are  found.  It  can  only  be  conjectured 
that,  owing  to  the  extremely  small  space  into  which  the  intestines  have 
been  squeezed,  they  get  thrown  into  angular  contortions  which,  when 
any  unusual  pressure  from  without,  or  distension  of  a  part  by  flatus  or 
otherwise  supervenes,  the  peristaltic  action  is  disordered,  and  there 
occurs  a  virtual  obstruction.  In  one  case  Rokitansky  found  a  fatal 
constriction  of  the  intestines  caused  by  the  rotations  of  the  tumor,  a 
dermoid  one. 

10.  In  other  cases  adhesions  have  been  found  which  were  sufficient 
to  account  for  the  intestinal  obstruction. 

11.  The  disappearance  of  the  disease  by  spontaneous  resorption  of 
the  fluid  and  shrivelling  of  the  cyst,  is  not  proved.  The  lining  mem- 
brane of  the  cyst  has  the  property  of  throwing  fluid  into  the  cyst  with 
extreme  facility,  but  not  in  the  converse  direction.  So  long  as  the  fluid 
is  confined  in  the  ovarian  cyst  it  is  beyond  the  influence  of  absorption. 
So  much  at  least  is  true  as  far  as  sure  clinical  experience  proves.  Cases 
do,  however,  occur  in  which  considerable  accumulations,  believed  to  be 
in  ovarian  cysts,  disappear  more  or  less  completely,  either  spontaneously 
or  under  the  use  of  diuretic  and  other  medicines.  A  little  time  ago 
there  was  a  woman  in  St.  Thomas's  Hospital,  under  the  care  of  Dr. 
Gervis  and  myself,  whose  history  gave  support  to  this  hypothesis.  She 
then  carried  a  very  large  ovarian  cyst  seemingly  single ;  two  years  be- 
fore, she  said,  she  had  one  nearly  as  large,  and  the  swelling  disappeared 
under  medicines,  water  passing  freely  by  the  bowels  and  bladder.  I 
cannot  help  suspecting  that  in  this  and  similar  cases,  the  fluid  escaped 


298  OVAEIAN    TUMOES. 

first  into  the  peritoneal  cavity  by  rupture  or  a  small  perforation,  or  else 
by  a  fistulous  channel  directly  into  the  bowel. 

12.  When  it  escapes  into  the  peritoneum,  the  fluid,  if  of  the  limpid 
kind,  may  be  taken  up  into  the  circulation  and  discharged  rapidly  by 
the  excreting  organs.  Numerous  cases  are  on  record  of  the  spontaneous 
or  accidental  bursting  of  ovarian  cysts,  followed  by  cure  in  this  way. 
If  the  walls  are  thin,  and  the  tumor  tense,  under  gradual  or  sudden 
pressure  or  violence  rupture  may  take  place. 

In  this  way  cysts  have  burst  under  the  rapidly  accelerated  pressure 
caused  by  the  simultaneous  growth  of  the  pregnant  uterus,  under  sud- 
den exertion,  under  direct  violence  as  of  a  blow,  or  under  concussion 
as  from  a  fall.  A  remarkable  case  occurred  in  the  temporary  St. 
Thomas's  Hospital.  A  woman  under  my  care  was  descending  in  the 
lift  to  take  the  air  in  the  grounds,  when  the  machinery  gave  way  and 
the  lift  came  down  the  last  few  feet  with  a  run.  The  concussion  burst 
the  tumor ;  large  quantities  of  watery  fluid  were  discharged  during  the 
next  few  days  by  the  bladder,  and  she  completely  recovered,  the  tumor 
not  returning. 

The  recovery,  however,  is  not  always  complete.  After  bursting  and 
absorption  of  the  fluid,  the  tumor  may  form  again,  just  as  we  see  after 
the  operation  of  tapping.  Thus  W.  F.  Soltau  relates  a  case  (Medical 
Times  and  Gazette,  1862)  in  which  the  cyst  burst  three  times  into  the 
peritoneum ;  the  fluid  was  voided  by  diuresis.  She  was  also  tapped 
thirty-seven  times.  She  died  after  the  bursting.  Disse  relates  a  case 
(Monatsschr.  fiir  Geburtsk.,  1860)  in  which  the  patient  recovered  from 
one  bursting,  the  fluid  being  discharged  by  the  kidneys.  After  a  few 
years  the  tumor  burst  again.  The  second  rupture  of  the  cyst  was 
verified  by  autopsy.  Obstinate  constipation  followed  the  accident, 
then  copious  watery  discharge  by  rectum ;  in  two  days  eighteen  quarts 
were  measured.  When  this  ceased,  profuse  discharge  of  urine  occurred ; 
during  five  days  eight  quarts  were  passed  daily.     She  sank  exhausted. 

Huguier  expressed  a  doubt  whether  cases  of  this  kind  were  really 
bursting  of  an  ovarian  tumor,  and  suggested  that  they  were  more  likely 
examples  of  simple  cysts  of  inflammatory  origin  attached  to  the  uterus. 
Matthews  Duncan  indorses  this  view,  "  regarding  cures  of  ovarian 
cysts  by  spontaneous  bursting  or  by  simple  puncture  in  a  high  degree 
doubtful,  and  considers  that  at  all  events  whilst  post-mortem  verifi- 
cation of  such  cures  is  absent  they  are  partly  explained  by  supposing 
that  instead  of  ovarian  dropsies,  inflammatory  serous  cysts,  cases  of 
serous  perimetritis  were  the  subjects  of  treatment." 

I  tliink  we  must  accept  this  explanation  for  some  of  the  cases  of 
presumed  cure  of  ovarian  cysts  following  rupture  or  simple  puncture. 
But  certainly  the  possibility  of  some  ovarian  cysts  being  so  cured 
seems  free  from  doubt.  In  the  case  at  St.  Thomas's,  above  referred  to 
as  having  been  caused  by  the  shock  of  a  fall,  the  ovarian  nature  of 
the  cyst  had  been  verified  by  repeated  examinations.  And  the  possi- 
bility of  an  ovarian  cyst  healing  after  rupture  is  proved  by  two  speci- 
mens in  Guy's  Hospital  Museum,  of  ovarian  cysts,  which  had  burst 
spontaneously,  the  rent  cicatrizing.  These  specimens  supply  the  post- 
mortem verification  which  is  said  to  be  wanting.     Tlie  first  specimen, 


COURSE.  299 

No.  2246^*  is  "  a  large  ovarian  cyst,  which  had  burst  spontaneously^ 
and  had  become  repaired."  Within  it  an  inverted  portion  of  the  old 
wall  is  seen,  and  a  reduplication  of  the  cyst  is  indistinctly  seen  in  the 
section.  The  case  was  that  of  Ann  B.,  aged  46,  under  I)r.  Addison, 
in  1836.  When  first  seen,  in  March,  1834,  she  stated  that  she  had 
had  children  at  an  early  age,  and  had  menstruated  regularly  since  ; 
that  five  years  before  she  observed  a  swelling  in  the  right  iliac  fossa, 
that  the  tumor  increased,  although  her  health  remained  good  until  ten 
days  ago,  when  she  fell,  and  struck  her  abdomen.  She  was  seized 
with  violent  pain,  sickness,  and  fainting,  and  then  perceived  that  the 
swelling,  which  was  before  local,  had  diffused  itself  over  the  abdomen. 
On  admission  she  was  suffering  from  acute  peritonitis.  She  soon  per- 
fectly recovered,  and  again  entered  into  domestic  service  in  1836,  only 
a  small  tumor  in  the  left  iliac  region  being  distinguishable.  She  died 
in  August,  1836,  and  the  sac  was  removed.  There  were  adhesions  in 
various  parts  of  the  abdomen ;  the  ovarian  cyst  occupied  the  pelvis, 
and  was  closely  connected  to  surrounding  parts.  It  contained  about 
two  quarts  of  a  reddish  thick  fluid,  and  the  lining  membrane  was 
covered  with  thick  layers  of  albuminous  matter.  Upon  the  front  of 
the  tumor  was  a  band,  formed  by  the  folding  of  the  walls  upon  them 
selves  as  the  cavity  shrank.  The  Avails  were  so  firmly  united  that  the 
reduplication  was  only  clearly  seen  when  a  section  was  made.  The 
rupture  had  been  about  eight  inches  in  length.  The  edges  of  the  rent 
had  not  united,  but  the  inferior  lip  was  found  floating  free  within  the 
cavity,  whilst  the  superior  lip  of  the  rent  was  glued  over  the  opening 
to  the  cyst  below. 

The  other  specimen,  No.  2239^*,  is  equally  decisive.  It  is  "a  ute- 
rus and  a  portion  of  a  large  cyst  from  the  left  ovary.  It  is  of  a  com- 
pound serous  kind,  and  had  burst  spontaneously  during  the  life  of  the 
patient,  from  which  accident  she  recovered,  and  survived  several 
months.  The  cicatrix  appears  in  the  portion  of  cyst  preserved.  The 
patient  died  from  malignant  disease  of  the  stomach."  The  specimen 
was  presented  by  Mr.  May,  of  Tottenham. 

There  is  a  third  specimen  in  the  same  museum,  No.  2231^^,  which 
although  less  striking  than  the  foregoing,  affords  evidence  to  the  same 
point. 

In  St.  Bartholomew's  Museum  is  another  specimen  (No.  31.31), 
which  illustrates  this  point.  It  "  is  a  portion  of  a  cyst  that  arose  from 
the  left  ovary.  It  communicates  with  the  ileum  by  a  small  aperture, 
between  four  and  five  inches  above  the  ileo-coecal  valve.  Some  weeks 
before  death,  after  the  discharge  of  a  large  quantity  of  fluid  per  anum, 
the  abdominal  tumor  had  diminished  in  size,  and  the  dulness  to  per- 
cussion over  its  region  had  been  replaced  by  tympanitic  resonance." 

These  cases  place  the  possibility  of  cure  of  ovarian  cystic  disease,  by 
rupture  or  perforation,  beyond  dispute. 

In  anotlier  class  of  cases,  perhaps  more  frequent,  the  patient  dies 
quickly,  killed  by  the  shock ;  or  if  she  rallies  from  shock,  peritonitis 
sets  in,  which  is  most  likely  to  prove  fatal.  This  danger  appears  to 
depend  in  great  measure  upon  the  qualities  of  the  fluid  effused.  If 
clear  and  watery  the  fluid  itself  may  cause  little  irritation ;  the  peri- 


300  OVARIAN    TUMORS. 

toneum  tolerates  it  well.  If  it  act  injuriously,  it  is  probably  chiefly 
because  it  is  voided  suddenly  in  large  quantity,  so  as  to  disturb  the 
balance  of  circulation  greatly.  It  is  the  shock  that  is  dangerous ;  the 
fluid  itself  is  harmless.  But  where  the  fluid  is  gelatinous  or  puriform 
it  is  clearly  not  favorable  for  absorption,  and  it  may  even  possess  acrid 
or  irritating  properties.  Hence  there  is  added  to  the  simple  shock,  re- 
tention in  the  peritoneum  of  an  irritating  fluid.  Peritonitis  is  inevita- 
ble ;  and  since  the  cysts  which  yield  fluid  of  this  nature  are  commonly 
multilocular  and  incurable  by  simple  tapping,  the  progress  of  the  tumor 
is  not  stopped.  If  the  patient  survive  the  shock  and  peritonitis,  the 
ovarian  disease  will  pursue  its  natural  course  notwithstanding.  Mr. 
Spencer  Wells  relates  a  case  (Medical  Times  and  Gazette,  1861)  in  which, 
after  ovariotomy,  the  serum  found  in  the  peritoneum  must  have  con- 
tained a  very  active  animal  poison.  He  himself  suffered  from  absorp- 
tion. Sometimes  when  a  cyst  bursts,  vessels  in  its  walls  are  torn,  and 
blood  to  a  considerable  extent  may  be  effused  into  the  peritoneum  along 
with  the  ovarian  fluid.  This  complication  increases  the  danger  of  peri- 
tonitis, and  adds  that  of  anseraia. 

13.  Bleeding  from  the  surface  of  the  cyst  or  into  its  interior  may 
take  place  without  rupture.  In  such  an  event  death  may  be  rapid 
under  symptoms  resembling  those  of  rupture  of  an  extra-uterine  gesta- 
tion cyst.  The  patient  may  bleed  to  death.  In  one  case  Mr.  Wells 
says  the  blood  escaped  through  the  Fallopian  tube  and  uterus  from  a 
large  cyst  in  the  ovary. 

14.  The  cyst  may  contract  adhesions  witli  the  bladder  or  bowel,  and 
bv  bursting  or  ulcerative  perforation  into  one  of  these  viscera,  its  con- 
tents may  be  discharged.  Communication  thus  established  with  the 
exterior  is  more  favorable  than  rupture  into  the  peritoneum.  The 
bladder  and  the  bowel — the  latter  especially — are  less  liable  to  injury, 
and  can,  moreover,  readily  get  rid  of  the  offending  matter.  In  this 
way  even  fluid  of  tenacious  or  gelatinous  nature  may  be  discharged. 
Thus  Ulrich  (Monatssch  f.  Geburtsk.,  1859)  relates  a  case  in  which  a 
large  quantity  of  thick  fatty  matter  was  emptied  by  the  bladder ;  it 
was  ascertained  to  be  pure  elain ;  several  quarts  were  passed.  For  a 
long  time  the  urine  contained  pus  and  fatty  matter.  The  patient  re- 
covered, some  remains  of  tumor  being  still  felt. 

The  London  museums  contain  several  interesting  examples  of  ovarian 
tumors  opening  into  the  hollow  viscera.  At  Guy's  is  a  specimen  (No. 
2228^-^)  from  a  woman,  aged  36,  under  Dr.  Gull,  in  1861,  for  Bright's 
disease.  At  the  same  time  there  existed  in  the  abdomen  a  remarkable 
tumor,  being  a  cyst  containing  fluid  and  air.  On  striking  it  a  loud 
splash  was  heard,  and  at  the  same  time  it  was  resonant  on  percussion. 
After  death,  on  opening  the  tumor,  a  fetid  gas  escaped,  and  at  its  lower 
part  was  a  turbid  purulent  fluid.  The  intestines  were  adherent  to  it, 
and  at  the  bottom  was  an  opening  communicating  with  the  upper  part 
of  the  rectum. 

Dr.  Murchison  (Path.  Trans.,  vol.  xviii)  relates  the  following:  E.  C, 
aged  37,  for  eight  years  had  been  liable  to  general  dropsy  and  attacks 
of  erysipelas  of  the  face.  About  eighteen  months  before  admission  to 
Middlesex  Hospital  she  first  noticed  a  swelling  in  the  lower  part  of  the 


COURSE.  301 

abdomen.  On  admission,  the  abdomen  was  distended  by  a  tumor  rising 
above  the  pubes.  The  urine  contained  albumen.  The  patient  began 
to  suifer  from  diarrhoea ;  the  stools  contained  blood.  This  continued 
for  sixteen  days,  during  which  time  there  was  no  diminution  in  the 
size  of  the  abdomen.  Then  the  stools  contained  a  quantity  of  pus, 
which  went  on  for  three  days,  and  in  a  week  all  signs  of  the  tumor  had 
disappeared.  The  patient  sank  two  or  three  days  later.  The  liver, 
spleen,  and  kidneys  were  very  large.  A  collapsed  cyst,  the  size  of  a 
cocoanut,  was  seen  in  the  situation  of  the  uterus.  This  was  a  cyst  of 
the  left  ovary,  which  had  emptied  itself  by  an  opening  the  size  of  a 
fourpenny  piece  into  the  rectum  four  inches  above  the  anus. 

In  St.  Thomas's  Museum  is  a  specimen  (FF,  45)  of  a  fecal  abscess 
communicating  with  an  ovarian  cyst.  The  lower  end  of  the  rectum, 
the  vagina,  and  the  uterus  with  its  appendages  are  included  in  the 
specimen.  The  lower  end  of  the  rectum  is  very  much  constricted,  and 
its  inner  surface  is  very  irregular ;  above  are  two  sinuses  which  lead 
into  fecal  abscesses  situated  in  the  cellular  tissue  external  to  the  rectum. 
One  of  these  abscesses  is  seated  between  the  rectum  and  uterus,  and 
communicates  superiorly  with  a  cyst  about  the  size  of  a  walnut  in  the 
right  ovary.     From  a  woman,  aged  40,  who  died  of  phthisis. 

When  pregnancy  intervenes,  the  risk  of  a  fatal  issue  is  vastly  in- 
creased. I  have  discussed  this  subject  at  some  length  in  my  work  on 
"Obstetric  Operations,"  second  edition,  1871. 

Perforation  must  be  distinguished  from  bursting.  Perforation  is  a 
gradual  process,  and  is  more  likely  to  occur  in  the  glandular  cystomas 
than  in  the  simple  cysts.  An  opening  may  be  effected  direct  into  the 
peritoneum,  but  more  commonly  into  a  hollow  organ.  The  causes  of 
perforation  are :  1,  a  wearing-through  of  the  cyst-icall  by  partial  pressure 
of  the  growths  from  within  of  a  papillary  cystoma.  The  dendritic 
cauliflower  growths,  springing  from  any  spot,  advance  to  the  opposite 
side,  and  if  large,  cause  perforation  by  pressure.  They  may  then  grow 
on  unhindered  in  the  peritoneal  space,  and  sooner  or  later,  cause  fatal 
j)eritonitis  (see  Fig.  73).  2d,  suppuration,  which  is  the  most  frequent 
cause  of  perforation.  In  this  case  the  opening  is  seldom  into  the  peri- 
toneum; it  mostly  opens  externally  or  into  a  neighboring  hollow  organ. 
Dr.  O.  Spiegelberg  relates  some  good  illustrative  cases  (Arch.  f. 
Gynakologie,  1870.) 

Dr.  Bristowe  described  these  perforations  (Path.  Trans,,  1853,  vol. 
v),  having  several  times  seen  perforations  of  ovarian  tumors  into  the 
peritoneum,  precisely  resembling  those  between  the  cysts  themselves, 
and  (vol.  xii)  says  it  is  extremely  common.  Adjoining  cysts  are  con- 
stantly opening  into  one  another ;  and  cysts  are  almost  as  constantly 
rupturing  into  the  abdominal  cavity.  In  both  cases  the  steps  of  the 
process  are  identical :  first,  the  outer  surface  of  the  wall  yields  at  iso- 
lated points,  in  consequence  of  the  distension  due  to  the  accumulating 
fluid  within,  and  circular  or  oval  depressions  of  various  sizes  are  pro- 
duced; secondly,  these  enlarge  in  area,  and  deepen,  and  finally  per- 
forate ;  thirdly,  the  contents  of  the  cyst  escape,  the  cysts  collapse  more 
or  less,  atrophy,  and  ultimately  (in  consequence  of  the  growth  of  new 


302  OVARIAN    TUMORS. 

cysts  in  their  walls,  of  the  enlargement  of  neighboring  cysts,  and  of 
their  own  shrinking)  form  irregular  crescentic  or  sinuous  folds. 

Most  commonly  these  perforations  are  attended  by  adhesions  which, 
uniting  the  cyst  with  a  hollow  organ,  form  a  substance  through  which 
a  fistulous  tract  is  gradually  made.  In  this  way  the  abdominal  cavity 
is  protected.  I  believe  that  it  is  through  small  perforations  occurring 
that  the  frequent  attacks  of  peritonitis  are  produced;  and  that  we  may 
thus  look  upon  the  adhesions  so  commonly  found,  as  the  effect  and 
evidence  of  a  conservative  process  enacted  to  limit  the  mischief.  No 
sooner  does  a  minute  perforation  take  place  than  the  opening  is  glued 
up  by  plastic  effusion. 

But  sometimes  adhesions  do  not  form  in  time.  Then  the  perfora- 
tion allows  the  contents  of  the  cyst  to  escape  into  the  peritoneal  cavity, 
and  the  result  may  be  quickly  fatal. 

In  St.  Thomas's  Museum  (No.  FF  32)  is  an  example  of  spontaneous 
perforations  in  an  ovarian  cyst.  The  perforations  allowed  free  com- 
munications with  the  abdominal  cavity  ;  their  edges  were  well-defined, 
and  bevelled  off  at  the  expense  of  the  outer  edge.  The  following  speci- 
men (No.  FF  33)  is  another  example  of  the  same  kind. 

Occasionally  adhesions  form  to  the  diaphragm,  and  the  ulcerative 
process,  continuing  in  an  upward  direction,  the  pleurae  and  lung  may 
be  attacked. 

In  the  College  of  Surgeons  is  a  specimen  (No.  2623)  consisting  of  a 
portion  of  diaphragm,  with  part  of  a  large  ovarian  cyst  firmly  adherent 
to  its  peritoneal  surface.  On  the  inner  surface  of  the  cyst  there  are 
numerous  smaller  cysts  and  tumors  connected  with  it,  and  with  one 
another  by  pedicles  and  bands  of  false  membrane.  A  portion  of  lung 
adheres  to  the  corresponding  pleural  surface  of  the  diaphragm.  The 
cyst  had  been  tapped  several  times,  but  could  not  be  completely 
emptied,  for  it  was  sacculated.  It  adhered  firmly  to  most  of  the  ab- 
dominal viscera.     (From  MSS.  of  Geo.  Langstaff.) 

Sometimes  the  ulcerative  process  works  from  the  intestines  towards 
the  cyst. 

Dr.  Bristowe  (Path.  Trans.,  vol.  xiv)  presented  a  case  of  communi- 
cation between  an  ovarian  cyst  and  the  rectum.  There  was  an  exten- 
sive ulceration  of  the  mucous  membrane  of  the  large  intestine.  The 
patient  suffered  from  phthisis.  In  this  case,  the  ovarian  cyst  had  not 
opened  into  the  bowel,  but  the  intestine  ulcerated  and  opened  into  the 
cyst.  Fecal  abscesses  had  first  formed,  one  of  which  had  perforated 
the  ovarian  cyst. 

Ovarian  cysts  may  also  discharge  through  the  Fallopian  tubes. 
Richard  cites  cases  of  cysts  which  had  involved  a  considerable  portion 
of  a  tube,  through  which  their  contents  could  be  forced  into  the  uterus. 
The  portion  of  tube  implicated  had  become  increased  in  lengtli  and 
thickness,  and  the  folds  of  its  mucous  membrane  were  partly  effaced. 
A  distinct  aperture  between  cyst  and  tube  was  found.  In  these  cases 
the  a])erture  was  no  doubt  effected  by  a  gradual  perforative  process, 
not  by  bursting. 

Apart  from  bursting,  if  not  from  perforation,  intercurrent  attacks  of 
peritonitis  are  common  in  the  progress  of  ovarian  tumors.     Such  an 


COURSE.  303 

attack  may  prove  fatal,  but  more  commonly  recovery  takes  place, 
leaving  adhesions  of  tumors  to  the  walls  of  the  abdomen  and  viscera. 

15.  Inflammation  in  the  interior  of  the  cysts  also  not  seldom  occurs. 
It  is  of  a  low  kind,  and  suppuration  is  often  the  result.  This  process 
may  be  limited  to  one  or  more  of  the  cysts,  others  retaining  their 
pristine  condition.  There  is  reasonable  presumption  that  suppuration 
has  taken  place  inside  a  cyst,  if  symptoms  of  hectic  or  irritative  fever 
set  in  after  acute  pain  in  the  seat  of  the  tumor.  "When,"  says  Mr. 
Wells,  "the  temperature  of  the  patient  is  high,  ranging  from  100°  or 
101°  F.  in  the  morning  to  103°  or  104°  at  night,  and  emaciation  is 
progressive,  appetite  lost,  thirst  troublesome,  sleep  disturbed,  nausea  or 
vomiting  distressing,  and  the  abdomen  tender  on  pressure,  with  hurried 
pulse  and  respiration,  it  is  extremely  probable  that  one  or  more  cysts 
may  contain  pus ;  and  when  these  symptoms  are  present  in  an  extreme 
degree,  or  have  lasted  for  a  considerable  time,  the  pus  has  become  fetid." 

16.  The  roof  of  the  vagina  may  burst,  and  allow  the  ovarian  tumor 
to  protrude  through  it.     (See  Mr.  Berry's  case,  p.  304.) 

Luschka  also  (Monatsschr.  fiir  Geburtsk.,  1867)  relates  a  case  of  rup- 
ture of  the  vagina,  and  protrusion  of  an  ovarian  tumor. 

The  rate  of  growth  or  natural  duration  of  ovarian  cysts  varies  with 
the  kind  of  tumor,  and  other  circumstances,  one  of  which  is  the  age 
of  the  patient.  The  simple  non-malignant  cysts  generally  go  on 
steadily  increasing,  attaining  a  size  that  entails  distress  of  breathing 
and  danger  to  life,  in  about  two  or  three  years  from  their  first  attract- 
ing attention.  But  it  is  almost  certain  that  the  earlier  stages  of  growth 
may  extend  over  a  considerable  time  before,  either  by  bulk  or  pressure 
on  the  abdominal  viscera,  the  tumor  is  noticed  by  the  patient.  We 
have,  then,  an  unknown  quantity  to  add  to  the  known;  and  this  cir- 
cumstance frustrates  all  attempt  to  arrive  at  a  precise  estimate  of  the 
rate  of  gro^vth  or  duration.  Not  seldom  there  are  alternations  of  in- 
crease, and  of  standing  still.  After  remaining  passive  for  a  consider- 
able time,  a  stage  of  rapid  accumulation  may  set  in.  Scanzoni  believes 
menstruation  stimulates  the  growth.  The  partly  solid  non-malignant 
tumors  may  last  many  years,  growing  very  slowly,  thus  admitting  of 
gradual  adaptation  of  the  compressed  organs,  and  of  the  system  gener- 
ally, to  the  inconvenience,  before  distress  becomes  intolerable,  or  a  fatal 
result  ensues.  I  have  known  distinct  evidence  of  ovarian  tumors  to 
extend  over  twenty  and  even  thirty  years. 

The  malignant  and  proliferous  forms  proceed  more  rapidly.  The 
history  of  many  of  these  cases  is  brief.  It  is  measured  by  months 
rather  than  by  years. 

In  cases  of  long  standing,  oedema  of  the  legs  is  a  frequent  conse- 
quence. It  is  caused  either  by  pressure  on  the  renal  vessels,  inducing 
hypersemia  of  the  kidneys,  by  independent  or  induced  Bright's  disease, 
by  pressure  on  the  pelvic  veins,  or  by  thrombosis  in  the  pelvic  and 
femoral  veins.  In  the  latter  case  the  prognosis  is  bad,  as  it  generally 
indicates  malignant  disease  spreading  into  the  broad  ligaments,  and 
matting  the  pelvic  structures  together.  If  ascites  be  added,  the  proba- 
bility of  malignant  disease  extending  to  the  abdominal  glands  and 
other  structures  is  much  increased. 


304  OVAKIAN    TUMORS. 

The  eifects  of  ovarian  cystic  disease  upon  the  proper  ovarian  func- 
tions are  various.  We  have  seen  that  in  many  cases  ovulation  may  go 
on.  Even  in  a  diseased  ovary  a  portion  may  remain  unafiected,  and 
suffice  to  stimulate  menstruation.  And,  although  in  many  cases  it  ls 
found  that  both  ovaries  are  invaded,  yet  it  is  rare  that  the  proper  struc- 
ture of  both  is  entirely  destroyed.  In  some  cases,  perhaps  exceptional, 
and  only  for  a  time,  there  is  menorrhagia.  INIore  frequently  menstrua- 
tion becomes  scanty,  and  at  last  ceases.  This  undoubtedly  is  often  the 
consequence  of  general  dyscrasia.  That  menstruation  may  go  on  is 
p'rimd  facie  evidence  of  the  possibility  of  conception.  It  is  a  fact  that 
in  many  cases  pregnancy  does  take  place.  It  may  even  go  on  to  the 
natural  term,  and  delivery  take  place  without  accident.  I  have  known 
examples  of  several  successive  pregnancies  thus  being  accomplished. 
Bat  the  risk  is  serious.  In  another  class  of  cases  the  uterus  is  unable 
to  pursue  its  full  development,  and  abortion  or  premature  labor  sets  in. 
Fatal  injury  to  the  tumor  has  been  sustained  during  labor  from  the 
pressure  of  the  child,  or  from  the  necessary  operations  to  effect  deliv- 
ery.  The  tumor  has  on  many  occasions  burst  during  the  pregnancy  or 
labor,  generally  with  a  fatal  result.  There  is  an  extraordinary  speci- 
men in  St.  Bartholomew's  Museum  (No.  31.34)  contributed  by  Mr. 
Berry,  of  Bu-mingham.  It  is  an  ovarian  cyst  which  had  protruded 
through  the  external  parts  by  rupture  of  the  vagina  during  labor,  and 
which  was  afterwards  removed  by  ligatures  with  success — a  singular 
instance  of  ablation  of  an  ovarian  tumor  by  this  route. 

On  the  other  hand,  the  uterus  may  rupture  from  the  obstruction  to 
labor  caused  by  an  ovarian  cyst.  (Ogier  Ward,  Path.  Trans.,  vol.  v.) 

The  breasts  are  often  affected.  In  some  cases  they  become  tumid, 
even  yield  a  little  milky  fluid,  and  the  areola  is  darkened.  This 
chiefly  happens  during  the  earlier  stages  of  the  active  tumors.  Gener- 
ally when  the  disease  is  of  long  standing,  the  breasts  become  flaccid, 
and  shrivel.  This  may  be  an  indication  that  the  follicular  structure 
of  the  ovary  has  been  destroyed. 

The  origin  of  ovarian  cystic  tumors  is  frequently  so  little  marked 
by  recognized  symptoms  that  the  date  when  they  began  cannot  be  de- 
termined. Many  proceed  insidiously,  without  causing  distress  or  at- 
tracting notice,  until  they  have  made  some  perceptible  enlargement  of 
the  abdomen.  On  the  other  hand,  in  many  instances,  dysmenorrhoea 
has  preceded  the  development  of  the  tumor;  and  in  many,  attacks 
of  severe  pain  in  the  ovarian  region  have  been  noticed,  suggesting 
that  the  initial  condition  was  an  inflammation  of  the  ovary.  In 
some  cases,  the  tumor,  whilst  of  small  size,  gets  into  the  retro-uterine 
pouch,  pushes  the  uterus  forwards  against  the  bladder,  and  causes  re- 
tention of  urine. 


DIAGNOSIS.  305 


CHAPTER  XXXII. 

DIAGNOSIS  OF  OVARIAN  TUMORS. 

The  Diagnosis  of  Ovarian  Tumors  involves  the  analysis  of  all  ab- 
dominal tumors.  The  recognition  of  an  ovarian  tumor  really  involves 
very  often  the  decision  between  life  and  death.  Whether  an  operation 
of  a  most  severe,  possibly  fatal,  nature  shall  be  performed  or  not,  de- 
pends upon  the  diagnosis.  And  if  we  do  not  operate  for  want  of  an 
accurate  diagnosis,  the  patient  may  equally  incur  the  penalty  of  death. 
The  pregnant  uterus  has  been  tapped  or  opened  in  mistake  for  an  ova- 
rian tumor.  An  ovarian  tumor  has  been  often  mistaken  for  pregnancy ; 
and  this  latter  error  may  subject  the  patient  to  an  imputation  of  dis- 
honor,, than  which  death  itself  will,  to  some  minds,  appear  more  toler- 
able. 

The  first  point  to  determine  is  the  presence  or  absence  of  pregnancy. 
Dr.  Peaslee,  in  his  excellent  work  on  "Ovarian  Tumors"  (1872),  ob- 
serves that  the  diagnosis  of  pregnancy  in  the  early  months  does  not 
come  into  practical  consideration,  since  it  is  only  when  ovarian  tumors 
have  attained  the  size  of  the  gravid  womb  at  five  months  or  more,  that 
the  question  of  extirpation  arises.  But  there  are  other  reasons  for  form- 
ing a  diagnosis  at  even  the  earliest  stage.  A  proper  weight  must  be 
given  to  the  evidence  of  history.  This  may  or  may  not  be  useful ;  but 
it  is  not  safe  to  rely  upon  anything  but  physical  exploration.  We  must, 
then,  make  a  systematic  search  for  the  objective  signs  of  pregnancy. 
We  must  examine  the  breasts ;  observe  the  degree  of  tension,  the  veins 
running  to  the  areolae,  the  pigmentation  and  area  of  the  areolae,  the  de- 
velopment of  the  follicles,  the  presence  or  absence  of  milky  secretion. 
Then,  examining  the  abdomen  by  careful  palpation,  we  search  for  uterine 
and  foetal  movements ;  by  stethoscope  in  the  groins  and  oyer  the  abdom- 
inal tumor  we  listen  for  uterine  and  foetal  sounds ;  by  vaginal  touch 
we  determine  the  softness  or  hardness  of  the  cervix  uteri,  the  patency 
of  the  OS,  its  relative  position  in  the  pelvis ;  the  presence  or  absence  of 
what  I  have  described  as  vaginal  roof-stretching,  that  is,  the  tense  in- 
clined plane  formed  by  the  enlarged  body  of  the  uterus  pressing  upon 
the  roof  and  anterior  wall  of  the  vagina — (see  Fig.  49,  p.  139) — and 
through  which,  if  the  uterus  be  pregnant,  we  may  feel  its  rounded  solid 
bulk.  Place  the  patient  on  her  back,  with  the  shoulders  a  little  raised, 
then  strike  upon  the  rounded  mass  of  the  uterus  in  front  of  the  cervix 
with  the  tip  of  the  finger,  to  elicit  the  phenomenon  of  ballottement ;  or, 
if  the  OS  be  patulous,  perform  this  experiment  cautiously  through  the 
OS.  If  we  thus  get  positive  evidence  of  pregnancy,  we  have  gained  an 
important  step  in  the  diagnosis  of  the  case.  But  it  must  not  be  hastily 
conckided  that  because  there  is  pregnancy  there  is  not  ovarian  tumor 
Both  may  coexist.     And  if  we  fail  to  bring  out  any  of  tlie  absolute  signs 

20 


306  OVARIAN    TUMORS. 

of  pregnancy  it  must  not  hastily  be  concluded  that  the  woman  is  not 
pregnant.  It  is  not  a  very  uncommon  thing,  even  in  an  uncomplicated 
case  of  pregnancy  of  three,  four,  or  even  five  months,  to  miss  the  une- 
quivocal signs.  And  there  are  cases,  rare  it  is  true,  in  which  the  preg- 
nant womb  is  sunk  out  of  reach  in  a  large  accumulation  of  ascitic  fluid. 
This  mostly  happens  in  connection  with  albuminuria,  when  there  is 
anasarca  as  well. 

BcdlottemeM,  usually  considered  so  conclusive  a  test  of  pregnancy,  is 
sometimes  fallacious.  Spencer  Wells  relates  two  cases  in  which  this 
phenomenon  was  marked,  although  there  was  ovarian  tumor  and  not 
pregnancy.  In  one  there  was  a  rather  solid  tumor,  complicated  with 
ascites.  Ballottement  was  produced  by  the  floating  of  the  tumor  in  the 
])eritoneal  fluid ;  in  the  other  case  there  was  a  large,  semi-solid  tumor, 
which,  through  the  vaginal  roof,  felt  like  the  head  of  a  child,  and  could 
be  moved  by  the  manipulation  which  produces  ballottement  of  the  foetus 
in  utero.  This  became  more  marked,  when  subsequently  some  ascitic 
fluid  collected ;  but  this  helped  rather  than  obscured  the  diagnosis,  as 
it  enabled  the  observer  to  isolate  the  tumor  from  the  uterus.  I  have 
seen  several  similar  cases. 

Before  discussing  the  special  or  particular  cases  for  diagnosis,  it  will 
be  convenient  to  describe  summarily  the  general  principles  of  proceeding 
l)y  which  we  determine  the  presence  of  an  ovarian  tumor.  These  flow 
partly  from  the  knowledge  acquired  of  the  nature  and  progress  of  these 
tumors,  and  partly  from  the  application  of  means  of  physical  exploration. 

The  means  at  our  command  are : 

1.  Inspection  of  the  Abdomen. — The  patient  should  be  on  her  back, 
with  the  abdomen,  and  at  least  the  lower  part  of  the  chest,  bare.  We 
tlien  note  the  shape,  size,  and  position  of  the  tumor.  An  ovarian  tumor 
generally  gives  the  abdomen  an  arched  form,  sometimes  uniform,  espe- 
cially if  the  tumor  be  mainly  monocystic;  sometimes  there  is  oblique 
or  sloping  form,  one  side  being  prominent,  another  depressed ;  this  in- 
dicates polycystic  tumor. 

Very  large  tumors  may  rise  under  the  ribs,  push  up  the  liver,  and 
make  place  for  themselves  by  everting  the  false  ribs  and  cartilages.  It  is 
not  uncommon  to  find  the  xiphoid  cartilage  protruded  forwards.  The 
i-ecti  muscles  are  sometimes  parted ;  and  the  tumor,  falling  forwards, 
may  even  find  a  resting-place  on  the  thighs  and  knees. 

Generally  the  abdomen  is  in  full  tension,  the  skin  is  shining,  and 
even  marked  by  scar-like  cracks,  as  in  pregnancy.  In  the  depending 
])arts,  especially  that  which  hangs  over  the  pubes,  the  skin  becomes 
thick  and  doughy  from  infiltration  of  serum  into  the  cellular  tissue. 
This  is  sometimes  so  great  as  to  give  a  brawny  or  hypertrophied  char- 
acter to  the  skin.     Furrows  and  ridges  are  thus  formed. 

The  form  of  the  abdomen  depends  upon  the  form  of  the  tumor.  If 
tiie  cyst  be  single  and  its  wall  thin,  so  that  it  has  yielded  easily  and 
uniformly  to  distension,  it  will  tend  to  arch  out  in  the  direction  of  least 
resistance ;  that  is,  forwards,  protruding  the  abdominal  wall.  The  um- 
bih'cus,  as  in  pregnancy,  is  pushed  out,  but  the  arching  of  the  abdomen 
from  below  the  xiphoid  cartilage  to  the  pubes,  is  even  more  prominent, 
generally,  than  is  the  bow  produced  by  the  pregnant  womb.     It  even 


DIAGNOSIS.  307 

seems  sometimes  to  point  above  the  umbilicus.  The  Avails  of  the  uterus 
are  not  merely  stretched,  like  an  ovarian  cyst;  they  grov\  and  the  uterus 
always  preserves,  more  or  less,  its  original  shape,  that  is,  it  is  compressed 
or  flattened  a  little  in  its  anterior  wall.  If  the  cyst  is  multiloeular  and 
the  cysts  be  distended  unequally,  the  form  of  the  abdomen  will  be  un- 
equal ;  but  still,  as  one  cyst,  and  that  one  which  enlarges  in  the  direction 
of  least  resistance,  is  sure  to  be  most  anterior,  the  general  form  is  like 
that  of  the  monocystic  tumor.  In  the  early  stages  there  is  commonly 
more  prominence  on  one  side  of  the  abdomen,  one  iliac  region  being 
visibly  more  tumid  than  the  other.  By  inspection,  also,  we  observe 
the  peculiar  expression  of  countenance  which  attends  so  many  cases  of 
ovarian  disease.  This  is  often  so  striking  as  to  be  alone  diagnostic  to  the 
trained  eye.  ]Mr.  Spencer  Wells^  gives  a  drawing,  taken  from  a  pho- 
tograph by  the  late  Dr.  Wright,  which  represents  this  very  graphically. 
He  calls  it  the  "fades  ovariana."  The  emaciation,  the  prominent  or 
almost  uncovered  muscles  and  bones,  the  expression  of  anxiety  and  suf- 
fering, the  furrowed  forehead,  the  sunken  eyes,  the  open  sharply-defined 
nostrils,  the  long  compressed  lips,  the  depressed  angles  of  the  mouth, 
and  the  deep  wrinkles  curving  these  angles,  form  together  a  face  which 
is  strikingly  characteristic. 

2.  Mensuration  gives  more  precision  to  what  the  eye  has  observed. 
Carry  a  tape  from  the  spinal  column  round  on  either  side  to  the  um- 
bilicus or  linea  alba.  If  the  two  semi-circumferences  are  unequal,  this 
raises  a  presumption  in  favor  of  ovarian  tumor.  Another  measure- 
ment is  perhaps  more  useful.  Measure  from  each  anterior  superior 
spinous  process  of  the  ilium  to  the  umbilicus,  and  also  to  the  xiphoid 
cartilage.  These  comparative  measurements  will  show  clearly  the 
greater  protrusion  of  one  side,  if  it  exist.  Mensuration  is  more  valua- 
ble as  a  means  of  keeping  a  precise  record  of  the  increase  or  diminution 
of  the  size  of  the  abdomen, 

3.  Palpation. — By  feeling  with  the  outstretched  hands,  we  get  infor- 
mation as  to  the  size,  form,  and  solidity  or  waviness  or  penetrability  of 
the  abdomen.  If  the  hands  can  be  made  to  sink  in  a  marked  manner 
towards  the  spinal  column  below^  the  umbilicus,  the  presumption  against 
ovarian  tumor,  unless  a  very  small  one,  is  strong.  If  an  ovarian  tumor 
lie  behind  the  abdominal  wall,  this  is  impenetrable.  By  carrying  the 
open  hands  all  round  the  swollen  abdomen,  by  gentle  pressure  M^e  can 
often  determine  the  outline  of  the  underlying  tumor ;  we  make  out  the 
rounded  cyst  or  bag  which  contains  and  confines,  within  definite  limits, 
the  fluid  which  is  felt  waving  in  it.  This  sense  of  a  waving  fluid  is 
QaWeA  fluctuation.  It  is  most  clearly  brought  out  by  placing  one  hand 
spread  out,  or  one  or  two  fingers  lightly,  at  one  point  of  the  tumor, 
whilst  with  a  finger  of  the  other  hand  we  lightly  flip  in  another  part. 
By  shifting  the  positions  of  the  observing  and  the  striking  hands,  we 
explore  the  area  of  fluctuation  and  its  degree  in  different  parts.  If  the 
fluctuation  be  felt  freely  in  all  directions,  of  equal  force,  transversely, 
obliquely,  longitudinally,  along  the  extreme  breadth  and  length  of 
the  tumor,  the  inference  is  justifiable,  not  that  the  tumor  is  strictly 


Diseases  of  the  Ovaries. 


308  OVARIAN    TUMORS. 

raonocystic,  but  that  the  main  volume  of  the  fluid  is  contained  in  one 

If  we  find  there  is  fluctuation  in  one  part  of  the  tumor  and  not  in 
another ;  if  we  find  the  fluctuation  is  different  in  force  in  different 
parts  ;  if  we  find  the  wave  propagated  from  one  point  is  wholly  or  par- 
tially arrested  in  its  spread  across  to  another  part  of  the  tumor,  we  may 
infer  the  presence  of  septa  or  solid  parts. 

Plain  as  fluctuation  often  is,  this  sign  is  not  free  from  ambiguity.  I 
have  known  a  solid  fibroid  of  the  uterus  communicate  a  sense  of  fluctua- 
tion that  imposed  upon  skilful  observers.  And  we  may  have  what 
may  be  called  double  fluctuation.  There  may  be  ascites  as  well  as  ova- 
rian tumor.  Or  the  fluctuation  may  be  due  to  ascites.  The  latter 
case  will  be  diagnosed  by  and  by.  When,  as  not  unfrequently  hap- 
pens, there  is  fluid  in  the  peritoneal  cavity  as  well  as  in  an  ovarian 
tumor,  if  the  tumor  be  large,  the  peritoneal  fluid  will  be  diffused  as  a 
thin  layer  all  over  the  tumor.  Thus,  when  we  first  flip  the  abdomen, 
we  may  see  and  feel  a  light  wave  run  along  the  surface.  By  pressing 
the  fingers  rather  firmly  and  suddenly  into  the  abdomen,  we  may  dis- 
place the  thin  peritoneal  stratum,  and  come  down  upon  the  resisting 
bag  of  the  tumor  ;  then,  by  a  giving  a  rather  smart  impact  to  another 
part,  we  may  elicit  the  feel  of  another  deeper  fluctuation,  that  proper 
to  the  tumor. 

In  pregnancy,  also,  where  the  uterine  and  abdominal  walls  are  very 
thin,  and  the  quantity  of  liquor  amnii  excessive,  fluctuation  may  be  as 
distinct  as  in  some  cases  of  ovarian  dropsy. 

We  may  also  make  the  phenomena  of  fluctuation  available  in  deter- 
mining the  limits  of  the  sac.  Thus,  by  applying  two  observing 
fingers  spread  out,  so  as  to  leave  a  space  of  two  or  three  inches  between 
their  tips,  to  one  flank,  whilst  impact  is  given  by  the  other  hand,  we 
may  feel  fluctuation  by  the  upper  finger,  and  not  by  the  lower  one, 
showing  that  the  boundary  of  the  cyst  is  between  the  two  fingers. 

Intra-vaginal  touch  may  be  considered  as  a  form  of  palpation.  By 
this  touch  we  determine  some  of  the  physical  signs  of  pregnancy,  if 
this  condition  exist;  and,  in  the  contrary  event,  we  determine  the  posi- 
tion and  other  conditions  of  the  uterus,  and  some  of  the  relations  of 
the  ovarian  tumor.  The  conditions  found  in  some  very  early  cases 
:  will  be  described  under  the  head  of  "Special  Diagnosis  of  Early  Cases." 
In  advanced  cases,  where  the  tumor  has  assumed  the  balloon  shape, 
and  even  the  loAver  pole  of  it  is  too  large  to  enter  the  pelvic  brim,  the 
uterus  is  often  dragged  up  a  little,  and  tilted  on  one  side,  generally  to 
the  opposite  side  of  the  tumor;  the  os  is  generally  directed  backwards, 
the  fundus  fi)rwards.  The  vaginal  roof  is  mostly  covered  in  by  the 
spherical  pole  of  the  tumor ;  it  feels  elastic  if  the  tumor  is  monocystic, 
and  sometimes  fluctuation  may  be  transmitted  to  it  by  flipping  the 
abdominal  wall. 

The  upward  dragging  of  the  uterus  tends  to  obliterate  or  conceal  the 
vaginal  portion  of  the  uterus ;  it  is  draAvn  out  of  the  vagina,  so  that  the 
OS  uteri  is  often  felt  almost  flush  with  the  vaginal  roof  The  vaginal 
roof  itself  is  sometimes  drawn  up  into  a  cone.  In  the  opposite  class 
of  cases,  in  which  the  tumor,  or  a  part  of  it,  descends  in  Douglas's  space, 


DIAGNOSIS.  309 

this  space  is  much  enlarged,  the  posterior  vaginal  roof  is  distended  and 
made  to  protrude,  sometimes  so  as  to  be  prolapsed  beyond  the  vulva. 

The  touch  is  extended  by  the  uterine  sound.  But  before  using  it  we 
must  first  clearly  exclude  pregnancy.  This  instrument,  passed  into 
the  uterine  canal,  determines — 1,  the  length  of  the  uterus;  2,  its  in- 
clination or  position ;  3,  its  mobility  or  freedom  from  the  tumor.  If 
the  uterus  is  easily  moved,  and  of  its  ordinary  size,  it  may  be  inferred, 
not  only  that  the  tumor  is  extra-uterine,  but  also  that  the  pedicle  is 
long.  It  must,  however,  be  remembered  that  the  uterus  is  sometimes 
greatly  elongated  by  the  pressure  of  an  ovarian  tumor ;  and  if  the 
tumor  should  be  solid,  M^e  might  easily  fall  into  the  belief  that  it  was 
uterine. 

Vaginal  and  rectal  touch  is  further  of  great  service  in  determining 
other  questions,  especially  that  of  complication  with  malignant  disease. 
This  point  will  be  discussed  hereafter. 

The  information  obtained  from  inspection  and  palpation  is  corrected 
and  supplemented  by  that  obtained  from 

4.  Percussion. — This  is,  jjerhaps,  the  greatest  test.  It  may  be  said 
to  be  but  a  form  of  palpation,  but  it  brings  out  information  that  mere 
palpation  could  not  supply.  By  percussion  we  determine  the  areas  of 
dulness  and  of  resonance.  In  ovarian  cystic  tumor  the  relation  of  these 
areas  is  characteristic.  The  tumor,  arising  from  one  iliac  fossa,  pushes 
the  hollow  intestines  over  towards  the  opposite  side.  Whilst  the  tumor 
is  small,  that  is,  not  so  large  as  to  reach  the  level  of  the  umbilicus,  the 
contrast  between  the  dulness  of  the  side  where  the  tumor  lies,  and  that 
where  the  intestines  are  driven  to,  is  marked.  When  the  tumor  is  so 
large  as  to  reach  the  scrobiculus  cordis  this  contrast  is  not  so  obvious ; 
but  it  may  almost  always  be  traced.  The  intestines  lie  laterally  and 
inferiorly  in  the  space  between  the  last  false  rib  and  the  crest  of  the 
ilium  and  back  to  the  spinal  column,  because  the  cyst,  occupying  the 
opposite  side  of  the  abdomen,  has  left  only  this  space  for  the  intestines 
to  retreat  to ;  and  has  not  driven  them  directly  and  all  upwards,  because 
it  grew,  always  occupying  a  more  or  less  lateral  position.  The  con- 
trary of  this  happens  in  pregnancy  and  ascites,  in  which  conditions  the 
intestines  are  driven  straight  and  gradually  upwards,  the  gravid  womb 
rising  from  the  centre,  and  ascitic  fluid  filling  the  lower  parts,  to  rise 
with  its  level  uniformly  upwards.  Hence  we  have  in  cystic  tumors 
resonance  on  one  side,  between  the  last  false  rib  and  the  crest  of  the 
ilium,  whilst  on  the  op]:)osite  side  the  dulness  is  more  extensive,  because 
the  cyst  is  there.  So  much  may  be  taken  as  generally  true,  but  we 
must  guard  against  fallacies. 

In  pregnancy,  as  in  ovarian  »tumor,  the  intestines  are  so  crowded 
back  that,  whatever  the  position  of  the  patient,  the  dulness  is  heard  all 
over  the  front  of  the  abdomen,  whilst  there  is  an  area  of  resonance  in 
both  flanks.  In  advanced  pregnancy  there  is  often  marked  obliquity 
of  the  uterus;  it  inclines  so  much  to  one  side  that  the  area  of  resonance 
in  one  flank  may  be  notably  smaller  than  in  the  other.  And  in  ovarian 
tumor  we  almost  invariably  find  some  resonance  in  both  flanks,  although 
the  resonant  area  will  be  greater  on  one  side. 

5.  Auscultation  is  chiefly  of  use  in  determining  the  presence  of  preg- 


310  OVARIAN    TUMORS. 

nancy.  It  is  true  that  by  it  we  may  detect  a  friction-sound,  produced 
by  the  ascent  and  descent  of  the  tumor  under  the  respiratory  move- 
ments ;  and  sometimes  a  blowing-sound  in  one  groin,  which  might 
impose  for  the  souffle  of  pregnancy.  But  these  signs  are  of  minor 
clinical  value.  Some  variety  of  vascular  murmur  is  much  more  common 
in  uterine  tumors  than  in  ovarian.  It  is  synchronous  with  the  pulse. 
The  practiced  ear  will  distinguish  it  from  the  souffle  of  pregnancy. 

Practically,  it  is  not  necessary  in  every  case  of  suspected  ovarian 
tumor  to  go  systematically  through  all  the  above  cases,  with  a  view  to 
their  successful  elimination ;  or,  at  least,  the  experienced  clinical  phy- 
sician performs  this  elimination  so  rapidly  as  to  be  almost  unconscious 
of  the  process.  But  in  a  considerable  number  of  instances,  it  is  neces- 
sary to  enter  minutely  into  the  differentiation  between  some  two  of 
these  cases  before  we  can  decide  which  it  is  that  is  present, 
,  Nor  does  the  difficulty  end  here.  Two  or  more  of  the  above  cases 
may  coexist.  After  discovering  the  existence  of  some  one  of  the  con- 
ditions enumerated,  we  may  overlook  a  complication  which  is  masked 
by  the  prominence  of  that  which  we  have  discovered.  For  example, 
just  as  ovarian  tumor  may  be  complicated  with  pregnancy,  so  it  may 
be  complicated  with  uterine  fibroid,  or  with  ascites.  Nor  is  it  enough 
to  determine  the  presence  or  absence  of  complicating  tumors  or  fluid 
collections.  When  we  have  settled  that  there  is  an  ovarian  tumor  and 
nothing  else,  it  is  still  important,  with  a  view  to  forming  a  prognosis 
and  the  selection  of  the  mode  of  treatment,  to  determine — 1,  Whether 
the  tumor  be  monocystic  or  polycystic;  2,  whether  it  be  benign  or 
malignant;  3,  whether  or  not  adhesions  have  been  contracted  with  the 
abdominal  walls  and  viscera ;  4,  whether  the  uterus  be  enlarged,  or  in 
any  way  involved ;  5,  the  condition  of  the  general  health,  and  espe- 
cially the  presence  or  absence  of  diseases  of  other  organs,  as  of  the  heart, 
lungs,  liver,  kidney. 

A  sound  judgment  as  to  these  points  will  greatly  influence  the  choice 
between  tapping,  extirpation,  or  expectation. 

Diagnostic  research  must  be  applied  to  the  solution  of  the  following 
problems  : 

a.  Is  there  a  uterine  pregnancy  ? 

6.  Is  there  an  extra-uterine  pregnancy  ? 

c.  Is  there  an  extra-ovarian  cyst  ? 

d.  Is  there  enlargement  of  the  uterus  from  fibroid  tumor  or  fibro- 
cystic tumor? 

e.  Is  there  enlargement  of  the  omentum  and  intestines  ? 

/.  Is  there  enlargement  of  the  spleen,  liver,  pancreas,  or  kidneys? 

(/.  Is  there  pelvic  cellulitis  or  peritonitis  or  hsematocele? 

h.  Is  there  ascites  or  encysted  peritoneal  dropsy  or  abscess? 

i.    A  re  there  adhesions  ? 

j.    Is  the  tumor  benign  or  malignant? 

k.  Is  there  distension  of  the  bladder  or  fecal  accumulation  ? 

It  follows  from  the  foregoing  discussion  that  to  enter  pro])erly  jn-e- 
pared  upon  the  task  of  diagnosing  ovarian  tumor,  the  inquirer  nmst 
have  a  good  clinical  acquaintance  with  thoracic  and  abdominal  path- 


DIAGNOSIS. 


311 


ology.  A  most  masterly  memoir  bearing  directly  upon  this  point  will 
be  found  in  "  Guy's  Hospital  Reports,"  by  the  late  Dr.  Bright.' 

a.  Is  tha^e  a  uterine  pregnancy  f  This  initial  question  has  been 
already  discussed. 

6.  Is  there  an  extra-uterine  'pregnancy  f  This  question  trenches  to 
some  extent  upon  the  first,  a  ;  but  it  involves  many  points  quite  dis- 
tinct from  uterine  pregnancy.     Extra-uterine  pregnancy  is  rare ;  but 


Fig.  7G. 


Ovarian  tumor  aud  pregnancy. 

O  T,  the  tumor  lifted  out  of  tlie  pelvis  by  the  uterus,  u,  which  is  pushed  over  to  the  side  and 
over  the  brim  of  the  pelvis ;  r  h,  spot  where  festal  heart  may  be  heard. 

for  this  very  reason,  and  also  because  the  seat  of  the  tumor  which  it 
forms  is  more  nearly  identical  with  that  of  ovarian  tumor,  the  diag- 
nosis is  more  difficult. 

.  It  must  not  be  lost  sight  of  that  ovarian  tumor  may  be  complicated 
with  pregnancy,  uterine  or  extra-uterine.  In  the  case  of  uterine  preg- 
nancy we  may  expect  to  make  out  the  positive  signs  of  pregnancy ; 
but  these  will  be  likely  to  mask  those  of  the  ovarian  tumor.  One 
characteristic  of  the  double  condition  is  that  the  abdomen  is  moi'c 
widened  out  than  in  either  of  the  single  conditions ;  and  we  may 
usually  define  by  palpation,  percussion,  and  auscultation  the  limits  of 
each  tumor.     There  is  commonly  a  marked  sulcus  or  depression  of  the 


'  See  also  Now  Sydenham  Society's  edition  of  "  Bright's  Memoirs,"  vol.  vi,  1860. 


312  OVARIAN    TUMORS. 

upper  part,  where  the  two  spheres  diverge,  as  is  exemplified  in  the 
diagram,  Fig.  76,  taken  from  my  work  on  "  Obstetric  Operations," 
second  edition,  1870. 

In  ovarian  solid  tumors  it  almost  always  happens  that  the  tumor  is 
of  irregular  form.  There  are  projections,  angles,  sometimes  simulating 
limbs  of  a  foetus ;  but  they  do  not  move ;  nor  do  we  feel  that  peculiar 
vermicular  movement  characteristic  of  the  gravid  uterus.  We  may 
succeed  in  isolating  the  uterus  from  the  tumor  by  the  sound. 

If  the  uterus  be  at  all  fixed,  and  any  hardness  be  felt  around  it, 
examine  by  rectum  as  well.  If  malignant,  projections,  hard  and  irreg- 
ular, will  probably  be  felt  more  plainly  here. 

c.  Is  there  an  extra-ovarian  cyst  f  When  by  internal  and  external 
examination,  no  nodular  hardening  of  the  cyst-wall  can  anywhere  be 
detected,  where  the  cyst  is  uniformly  smooth  and  elastic  over  its  whole 
surface,  where  the  wave  of  fluctuation  is  equally  perceptible  in  all  direc- 
tions, the  inference  is  clear  that  the  cyst  is  practically  unilocular ;  and 
if  in  a  young  person  it  is  either  flaccid  and  of  long  duration,  or  exces- 
sively tense  and  of  recent  formation,  the  inference  is,  says  Wells,  almost 
equally  clear,  that  the  cyst  is  extra -ovarian  and  the  contents  limpid. 

It  is  a  good  practical  rule  in  any  case  presenting  the  above  charac- 
ters to  tap  in  the  first  instance,  as  this  simple  operation  will  probably 
be  sufficient  to  cure. 

d.  Is  there  enlargement  of  the  uterus  from  fibroid  tumor  or  hydrometraf 
This  is  one  of  the  great  practical  questions.  Under  the  belief  that  an 
ovarian  tumor  existed,  the  abdomen  has  many  times  been  laid  oj)en, 
only  to  discover  what  should  have  been  known  before,  namely,  that 
the  tumor  was  uterine.  The  diagnosis  is  not  seldom  extremely  diffi- 
cult, and  especially  so  when  the  tumor  is  fibro-cystic,  that  is,  containing 
fluid  so  superficially  placed  as  to  yield  the  phenomenon  of  fluctuation. 
The  uniformly  solid  tumors  ought  rarely  to  deceive,  so  far  as  to  carry 
one  into  the  practical  error  of  opening  the  abdomen.  Uniformly  solid 
ovarian  tumors  are  so  rare,  whilst  uniformly  solid  uterine  tumors  are 
so  much  the  rule,  that  if  I  were  disposed  to  be  aphoristic,  I  would  sub- 
mit no  aphorism  with  less  hesitation  than  this :  If  you  find  a  smooth, 
solid  tumor,  beware :  it  is  uterine.  If  a  solid  tumor  of  the  ovary  be 
rare,  a  large  solid  tumor,  so  large  as  to  give  rise  to  question  of  operating, 
may  be  said  to  be  amongst  the  curiosities  of  pathology. 

In  seeking  to  determine  whether  a  tumor  be  uterine,  we  must  be 
governed  greatly  by  what  vaginal  and  rectal  exploration  teaches  as  to 
the  condition  of  the  uterus.  The  great  point  is  to  determine  whether 
the  tumor  felt  above  the  pubes  is  continuous  or  identical  with  the 
uterus.  This  is  done  by  the  immediate  touch  by  finger  in  vagina,  by 
mediate  touch  by  sound  in  utero,  separately  and  combined  with  palpa- 
tion by  hand  outside  on  the  abdomen.  If,  by  these  means  we  ascer- 
tain— 1,  that  the  uterine  cavity  much  exceeds  two  and  a  half  inches  in 
length ;  2,  that  the  course  of  the  uterine  canal  is  tortuous  (a  flexible 
bougie,  which  will  worm  its  way  along  a  tortuous  canal,  is  sometimes 
better  than  the  metal  sound);  3,  that  the  body  of  the  uterus  is  directed 
backwards;  4,  that  the  bulk  of  the  tumor  moved  by  the  hand  outside 
communicates  a  continuous  movement  to  the  cervix,  as  felt  by  finger  or 


DIAGNOSIS.  313 

sound — we  may  fairly  infer  that  the  tumor  is  uterine.  This  inference 
will  be  strengthened  if  the  tumor  be  of  very  long  standing;  if  frequent 
metrorrhagia  have  been  suffered. 

But  it  is  right  to  declare  frankly  that  we  cannot  always  elicit  these 
phenomena,  although  the  tumor  is  fibroid ;  and  that  some  of  them,  when 
elicited,  are  not  absolute  proof  that  the  tumor  is  ovarian.  I  have  pro- 
nounced a  tumor  to  be  ovarian,  influenced  by  the  apparent  separate  mo- 
bility of  the  uterus,  in  a  case  where  the  tumor  proved  to  be  uterine. 
This  sign  is  very  deceptive.  The  great  bulk  of  the  uterine  tumor  may 
be  connected  with  the  uterus  by  a  comparatively  narrow  portion  below. 
At  this  narrowed  point  the  portion  of  the  uterus  below  it  may  easily  move 
upon  the  great  mass  above,  which  is  comparatively  fixed  by  its  volume 
and  solidity.  The  most  trustworthy  signs  are  the  increased  length  of 
the  uterus,  as  determined  by  the  sound,  and  the  solidity  of  the  tumor. 
How  the  cervix  uteri  may  be  elongated  is  illustrated  in  a  case  described 
by  Dr.  Bristowe  (Path.  Trans.,  vol.  v).  The  patient,  aged  24,  single, 
had  been  tapped  several  times  for  ovarian  dropsy,  in  St.  Thomas's.  The 
body  of  the  uterus  was  slightly  tilted  by  the  ovarian  growtli ;  no  os 
uteri  could  be  detected  at  first.  The  cervix  was  three  and  a  half  inches 
long,  and  formed  a  cylindrical  band,  about  half  an  inch  broad  and  one- 
third  of  an  inch  thick,  extending  between  the  os  and  the  uterus,  which 
was  somewhat  atrophied,  but  otherwise  healthy.  The  recto-vaginal 
pouch  had  become  much  distended,  pressing  the  posterior  wall  of  the 
vagina  forward  like  a  hernia.  This  had  exerted  a  certain  traction  upon 
the  OS  uteri,  and  through  the  latter  on  the  anterior  wall  of  the  vagina, 
and  by  long  continuance  caused  the  excessive  elongation  of  the  cervix 
uteri. 

It  is  not  very  uncommon  to  find  a  complication  of  fibroid  of  the 
uterus  with  ovarian  tumor.  In  such  a  case  we  must  carefully  weigh 
the  evidence  showing  that  both  organs  are  implicated. 

An  ovarian  tumor  of  moderate  size,  especially  if  in  great  part  solid 
or  semi-solid,  may  closely  simulate  a  uterine  fibroid,  if  there  be  great 
thickness  of  the  abdominal  wall.  A  thick  mass  of  fat  intervening  be- 
tween the  examining  hands  and  such  a  tumor  will  often  effectually  mask 
the  two  great  distinctive  features  of  an  ovarian  tumor,  namely,  fluctua- 
tion and  irregularity  of  surface.  We  must  depend  upon  careful  exam- 
ination of  the  uterus  by  the  vagina,  isolating,  if  possible,  this  organ 
from  the  tumor,  aided  by  abdominal  palpation  under  chloroform,  to 
establish  a  diagnosis. 

Dr.  C.  C  Lee  has  collected  nineteen  cases  of  fibro-cystic  tumor  of  the 
uterus,  and  has  analyzed  them,  with  the  view  of  establishing  grounds 
of  diagnosis  between  it  and  ovai'ian  tumor.^  As  proof  of  the  difficulty 
of  diagnosis,  it  is  stated  that  in  one  only  was  the  true  nature  of  the 
tumor  ascertained  before  operation.  Koeberle,  however,  thinks  the 
diagnosis  may  be  established  by  the  following  signs :  1.  The  discolored 
hue  and  dejected  expression  of  the  face,  the  so-called  fades  uterina  of 
the  patient.  2.  The  variable  consistency  of  the  tumor,  as  made  out  by 
abdominal  palpation.  3.  The  results  of  tapping.  If  the  trocar  touch 
a  fibrous  spot  in  the  tumor- wall,  blood  will  flow ;  even  when  the  cyst  is 

1  New  York  Journal,  1871. 


314  OVARIAN    TUMORS. 

reached  the  fluid  never  presents  the  clear  viscid  character  of  ovarian 
cystic  fluid,  but  is  either  yellowish,  thin,  serous,  and  rich  in  lymph  or 
cholesterin,  or  it  is  brown,  muddy,  sero-purulent,  or  bloody,  and  the 
tapping  leaves  only  partial  collapse,  4.  The  indurated  or  nodular  feel 
of  the  tumor  after  tapping.  5.  The  uterine  connections  of  the  growth, 
as  made  out  by  vaginal  uterine  examination,  by  aid  of  the  sound.  The 
uterus  is  more  displaced  than  in  ovarian  tumor. 

The  history,  although  liable  to  deceive,  must  be  taken  into  account. 
The  rate  of  development  of  ovarian  tumors  usually  gives  less  than  two 
years,  whilst  that  of  flbro-cystic  tumors  is  generally  much  slower.  But 
I  have  known  ovarian  tumors  last  forty  years.  Ovarian  tumors  begin 
early,  uterine  late.     But  the  variations  are  numerous. 

The  fluctuation  in  flbro-cystic  tumors  is  confined  to  certain  regions, 
generally  to  the  upper  part,  and  the  solid  portions  preponderate;  whilst 
in  ovarian  tumors  having  solid  elements,  the  fluctuating  parts  predom- 
inate, and  the  solid  element  is  almost  always  at  the  lower  part. 

We  must,  however,  be  prepared  to  flnd  all  the  above  signs  giving,  at 
best,  ambiguous  indications.  The  signs  most  common  in  flbro-cystic 
tumor  may  be  present,  or  appear  to  be  so,  in  ovarian  tumors,  and  vice 
versa.  Where  doubt  is  unavoidable,  error  is  excusable.  Hence  we  are 
occasionally  driven  to  the  exploratory  incision,  and  to  the  direct  exam- 
ination of  the  tumor.  This  gives  another  order  of  signs.  If  the  tumor 
be  uterine,  the  exposed  mass  is  dark,  vascular,  thick,  and  frequently 
fasciculated  with  fibrous  bands.  If  it  be  ovarian,  the  sac  is  usually 
pearly  white,  or  blue  and  glistening.  But  these  appearances  again  I 
have  seen  interchanged.  More  than  this,  even  after  removal  from  the 
body,  tumors  believed  by  the  operator  to  be  ovarian  have  turned  out  to 
be  fibroid  outgrowths  from  the  body  of  the  uterus,  more  or  less  pedun- 
culated. Mr.  Spencer  Wells,^  discussing  this  question,  says,  some  of 
the  largest  abdominal  tumors  he  has  ever  seen  have  been  fibroid  or 
flbro-cystic  tumors  of  the  uterus ;  and  more  than  a  hundred  cases  are 
on  record  where  the  abdomen  has  been  opened  with  the  object  of  remov- 
ing an  ovarian  tumor,  when  the  operator  discovered  that  it  was  uterine. 

The  aspirator-trocar  will  in  many  of  these  doubtful  cases  prove  of 
signal  value.  By  it  we  can  draw  off  some  of  the  fluid  from  the  cystic 
portion  for  examination. 

e.  Is  there  enlargement  of  the  omentum  and  intestines  f  At  the  climac- 
teric age,  a  woman,  falling  off'  perhaps  in  health,  notices  with  alarm  that 
she  is  increasing  in  size.  She  fears  that  it  is  due  to  a  growing  tumor. 
The  phantom-tumor  or  pseudocyesis  of  the  climacteric  period  has  been 
already  discussed.  We  have  now  to  eliminate  flbroid  and  ovarian 
tumors.  Where  there  is  nothing  but  fat  and  inflated  intestines,  we  may 
always  exclude  large  fibroids  and  ovarian  tumors  by  palpation  and  per- 
cussion. Resonance  in  front  may  be  dulled,  but  still  the  sound  is  dif- 
ferent from  the  dead  sound  returned  on  percussing  over  a  solid  or  fluid 
tumor.  The  hands  will  sink  in  towards  the  spine,  on  firm  pressure, 
especially  if  the  abdominal  muscles  are  made  to  relax  under  chloroform 

1  A  fourth  series  of  100  cases  of  ovariotomy,  with  remarks  on  the  diagnosis  of 
uterine  from  ovarian  tumors.     "  Med.-Chir.  Trans.,"  vol.  liv. 


DIAGNOSIS.  315 

or  under  expiration.  The  sensation  to  the  hands  is  doughy,  not  resist- 
ing. The  condition  of  the  uterus  can  commonly  be  determined  by 
vaginal  examination  and  by  sound,  so  as  to  leave  only  the  possibility 
of  ovarian  tumor  to  investigate.  And  here  we  come  to  the  practical 
difficulty  of  excluding  a  smcdl  ovarian  tumor.  This  may  be  buried  in 
one  iliac  region,  so  much  masked  by  surrounding  fat,  that  neither  by 
external  nor  by  internal  touch  can  we  get  at  it  so  as  to  bring  out  dis- 
tinctive characters.  It  may  help  us  to  remember  that  women  who  are 
storing  up  fat  do  not  commonly  have  ovarian  dropsy  or  pregnancy. 
These  states  usually  cause  emaciation. 

/.  Is  there  enlargement  of  the  liver,  spleen,  pancreas,  or  kidney  f  Tu- 
mors of  the  stomach,  liver,  spleen,  or  pancreas,  may  in  most  cases  be 
eliminated  by  evidence  showing  that  they  grow  from  above  downwards. 
This  may  generally  be  obtained  by  percussion.  If  dulness  prevail 
from  the  ribs  downwards,  leaving  an  area  of  resonance  below  the  tumor, 
that  is,  between  its  lower  margin  and  the  pelvis,  the  inference  that  the 
tumor  is  not  of  pelvic  origin  is  nearly  certain ;  and  this  probability  is 
greatly  increased  if  the  tumor  be  solid.  The  hydatid  of  the  liver  is  the 
condition  most  likely  to  deceive.  Here  we  may  have  fluctuation  and 
dulness  over  an  area  sometimes  very  similar  to  that  occupied  by  an 
ovarian  tumor.  The  history  and  the  peculiar  features  of  the  disease 
will  supply  diagnostic  indications.  We  shall  generally  have  a  resonant 
space  below  the  tumor.     The  hydatid  tremor  or  thrill  may  be  felt. 

Spiegelberg  relates'  a  case  of  echinococcus  of  the  right  kidney,  mis- 
taken for  ovarian  tumor,  and  operated  upon  with  a  fatal  issue.  The 
tumor  extended  from  the  ribs  to  the  pelvis,  and  was  felt  by  the  vagina. 
In  reading  this  case,  it  appears  to  me — it  is  so  easy  to  criticize  after  the 
event — that  the  tumor  was  more  strictly  confined  to  one  side  than  is 
usual  in  ovarian  tumor.  It  extended  all  along  the  right  side  from  ribs 
to  pelvis,  but  did  not  much  overlap  the  median  line. 

Cystic  disease  of  the  kidney  has  given  rise  to  mistakes.  So  long  as 
the  tumor  formed  by  this  disease  is  comparatively  small,  danger  of 
mistaking  it  for  an  ovarian  tumor  is  not  great.  The  dulness  and  fluc- 
tuation are  more  limited  to  one  lumbar  and  hypochondriac  region;  and 
an  area  of  resonance  will  be  made  out  between  the  tumor  and  the 
pelvis.  But  when  the  cystic  enlargement  is  very  great,  extending 
across  the  abdomen  and  below  to  the  pelvis,  the  diagnosis  is  not  easy. 
E,enal  tumors  growing  from  behind  press  the  intestines  forward,  so 
there  is  resonance  in  front.  Babington  and  Bright  pointed  out  that  in 
renal  disease  we  may  expect  changes  in  the  urine,  especially  an  abun- 
dance of  phosphates  and  lithates.  A  very  small  ovarian  tumor,  with  a 
long  pedicle,  might  be  mistaken  for  a  floating  kidney. 

I  have  known  a  considerable  area  of  resonance  between  the  pelvis 
and  a  tumor  seated  under  the  liver,  which  proved  to  be  ovarian.  This 
had  been  carried  up  and  rolled  over  on  its  axis,  the  pedicle  stretching 
and  twisting  under  the  pressure  of  a  growing  gravid  uterus. 

g.  Is  there  pelvie  cellulitis  or  peritonitis  or  hcematocelef  Here  a  his- 
tory of  sudden  or  rapid  development  under  symptoms   of  local  and 

1  "  Archiv  fiir  Gynakologie,"  1870. 


316  OVARIAN    TUMORS. 

general  distress  will,  when  given,  generally  be  sufficient.  But  often 
cases  come  before  us  with  no  history,  or  only  a  misleading  one.  In 
these  it  requires  great  care  to  distinguish  a  consolidated  mass  of 
omentum  or  intestines  found  near  the  pelvis  from  an  ovarian  tumor. 
This  condition  has  frequently  deceived,  even  to  the  extent  of  inducing 
the  surgeon  to  open  the  abdomen.  The  distinction  will  rest  mainly 
upon  the  more  solid  character  of  the  inflammatory  consolidation,  the 
absence  of  fluctuation,  and  perhaps  the  presence  of  deadened  resonance 
from  intestine  entangled  in  the  mass.  Here  again  the  aphorism 
which  warns  to  be  suspicious  of  a  solid  tumor  finds  useful  appli- 
cation. 

It  is  also  necessary  to  remember  that  peritonitis  or  hsematocele  may 
supervene  upon  ovarian  cystic  disease.  In  the  first  case,  that  of  peri- 
tonitis, it  is  singular  to  observe  how  an  area  previously  yielding  dis- 
tinct fluctuation,  becomes  hard,  almost  solid,  from  the  effusion  of  plastic 
matter  on  the  surface  of  the  tumor.  Where  there  has  been  no  oppor- 
tunity of  examining  before  the  inflammation  set  in,  it  is  not  easy  to 
avoid  the  error  of  concluding  that  there  is  a  solid  tumor  under  the 
hand.  In  the  absence  of  antecedent  knowledo'e  of  the  real  nature  of 
the  tumor  it  is  only  by  waiting  until  the  inflammatory  complication 
has  to  a  great  extent  disappeared,  that  we  can  be  sure  of  our  diagnosis. 

In  the  second  case,  that  of  hsematocele,  the  sudden  access  of  grave 
symptoms  at  once  arrests  attention.  Where  there  is  an  ovarian  tumor 
the  source  of  the  effused  blood  is  likely  to  be  the  tumor  itself.  Its 
walls,  or  large  vessels  on  its  surface,  may  have  burst.  Abdominal 
shock  is  the  first  result.  If  the  patient  survive  this,  peritonitis,  diffuse 
or  limited  to  the  pelvic  region,  follows.  This  will  give  rise  to  a  firm 
tumor  felt  projecting  into  the  rectum  and  vagina,  probably  rising  out 
of  the  true  pelvis  in  one  or  both  iliac  fossae,  and  pushing  the  uterus 
forward  against  the  symphysis  pubis. 

For  the  distinctive  characters  of  retro-uterine  hsematocele  I  must 
refer  to  the  chapter  on  this  subject. 

Pelvic  cellulitis  may  be  confounded  with  ovarian  tumor  under  two 
conditions :  first,  where  there  is  tumor  only ;  and  secondly,  where  there 
is  a  tumor  which  has  burst,  and  is  discharging  purulent  matter.  In 
the  first  case,  the  history  is  important.  Pelvic  cellulitis  is  usually  of 
recent  formation.  It  has  come  on  with  acute  symptoms  after  labor, 
abortion,  suj)pressed  menstruation,  surgical  treatment,  or  other  acci- 
dent; it  sets  the  uterus  fast  in  a  collar  or  framework  of  hard  effusion, 
in  the  brim  of  the  ])elvis,  so  that  the  body  of  the  uterus  cannot  be  dis- 
tinguished. The  uterus  is  not  so  affected  in  ovarian  tumor.  If  there 
be  fluctuation,  there  is  commonly  redness  of  the  skin  and  the  peculiar 
oedematous  feel  of  the  tissues  where  the  fluctuation  is  due  to  abscess. 
The  pelvic  distress,  including  dysuria,  is  marked  in  cellulitis,  rarely  so 
in  ovarian  dropsy. 

Where  there  is  escape  of  pus,  this  may  be  due  to  the  perforation  of 
a  suppurating  ovarian  cyst.  But  this  is  a  rare  event ;  whilst  it  is  a 
frequent  issue  of  pelvic  cellulitis.  And  it  usually  occurs  within  a  few 
weeks  of  the  commencement  of  pelvic  cellulitis ;  whereas  it  is  extremely 
rare  for  an  ovarian  tumor  to  suppurate  and  discharge,  until  it  has  at- 


DIAGNOSIS.  317 

tained  a  large  size,  that  is,  until  it  is  of  considerable  duration.  But 
these  features,  clear  enough  when  the  whole  course  of  the  disease  has 
passed  under  our  observation,  are  not  so  clear  if  we  are  called  to  a  case 
of  long  standing.  For  example,  although  pelvic  cellulitis  usually  runs 
a  tolerably  definite  course  within  a  short  time,  cases  occur  where  ab- 
scesses burst  after  some  moiiths,  or  at  least  in  which  suppuration  goes 
on,  and  matter  is  discharged  for  months  together  by  the  vagina  or  rec- 
tum. It  is  not  always  easy,  under  such  circumstances,  to  decide  that 
the  source  of  the  pus  is  not  an  ovarian  cyst;  especially  as  a  cyst,  dur- 
ing the  process  of  suppuration  and  perforation  of  the  vagina,  is  likely 
to  liave  set  up  pelvic  peritonitis.  This  complication  may  be  very 
puzzling;  and  we  shall  often  be  driven  to  the  history  for  data  upon 
which  to  found  a  presumption  one  way  or  the  other.  The  necessity, 
however,  of  forming  a  precise  diagnosis  in  such  case  is  of  minor  urgency, 
since  even  if  we  attained  to  the  certainty  of  its  being  ovarian,  the  high 
probability  of  extensive  pelvic  adhesions  would  forbid  the  attempt  at 
extirpation. 

h.  Is  there  ascites,  or  peritoneal  encysted  dropsy,  or  abscess  f  The 
distinction  between  pure  ascites  and  pure  ovarian  dropsy  is  rarely  so 
difficult  as  to  induce  error.  But  the  two  conditions  are  so  frequently 
associated  that  the  subject  demands  discussion.  The  grand  character- 
istics of  ascites  are :  that  in  the  intestines,  floating,  anchored  to  the 
mesentery  if  the  patient  be  on  her  back,  there  will  be  clear  resonance 
in  front,  where  in  ovarian  dropsy,  pregnancy,  and  fibroid  of  the  uterus 
there  is  dulness ;  that  the  dulness  will  be  in  the  lumbar  regions  be- 
tween the  false  ribs  and  the  crests  of  the  ilia,  where  the  fluid  gravitates, 
and  where  there  is  resonance  in  ovarian  dropsy  and  pregnancy ;  that 
the  areas  of  resonance  and  dulness  will  shift  on  changing  the  position 
of  the  patient,  because  the  hollow  intestines  float  to  the  surface,  whereas 
in  cystic  dropsy  and  pregnancy  these  areas  do  not  shift.  If  percus- 
sion be  performed,  the  patient  lying  on  her  back,  the  fluid  in  ascites 
gravitating  to  the  flanks,  and  the  intestines  floating  up  to  the  front, 
the  areas  of  resonance  and  dulness  will  be  as  in  Fig.  77.     In  ovarian 

Fig.  77. 


A.  Ascitic  dulness.    i.  Intestinal  resonance,    l.  Liver. 

dropsy,  the  areas  of  resonance  and  dulness  will  be  exactly  the  reverse, 
as  in  Fig.  78,  and  will  not  vary  under  change  of  posture. 


318 


OVARIAN    TUMORS. 


A  striking  contrast  between  ascites  and  ovarian  tumor  may  also  be 
demonstrated  by  percussing  in  the  erect  posture.     In  ascites  the  line 


O  T.  Dull  area  of  ovarian  tunior.    I.  Intestinal  resonance.     L.  Liver. 

of  demarcation   between  dulness  and  resonance  is  concave,  whilst  in 
ovarian  tumor  it  is  convex.     This  contrast  is  seen  in  diagram,  Fig.  79. 

Fig.  79. 


Differential  characters  of  ovarian  and  ascitic  droiDsies  in  upright  posture. 


Again,  ascites  is  the  consequence  and  therefore  a  symptom  of  disease 
of  the  heart,  liver,  or  kidneys.  The  history  and  other  symptoms  of 
these  diseases  will  guide  to  a  right  appreciation  of  the  dropsy. 

There  is  a  form  of  encysted  dropsy,  the  result  of  peritonitis,  in  which 
the  peritoneum  of  the  pelvic  organs  may  or  may  not  be  involved. 
Peritonitis  may  be  greatly  limited  to  a  portion  of  the  omentum,  and 
of  the  small  intestines  covered  by  it.  Plastic  matter  may  be  so  thrown 
out  as  to  form  a  cavity  or  cyst  between  these  parts  in  which  serum  is 
imprisoned.  I  saw  a  case  which  I  concluded  to  bo  of  this  kind  some 
years   ago   in   consultation   with   Dr.  Clapton  and   Mr.  Litchfield   of 


DIAGNOSIS.  319 

Twickenham.  There  was  a  large  tumor  in  the  riglit  flank,  passing 
across  the  median  line,  and  giving  fluctuation,  which  could  be  traced 
downwards  to  the  iliac  fossa.  It  had  been  looked  upon  as  certainly 
ovarian.  The  circumstances  that  made  me  doubt  were  the  rapidity 
with  which  the  tumor  had  formed ;  the  severe  attendant  pain  and 
history  of  fever ;  a  certain  singular  thickness  and  doughiness  of  part 
of  the  walls ;  and  the  more  marked  lateral  site  of  the  tumor  than  is 
usually  found  in  ovarian  cysts.  I  punctured  the  cyst ;  and  in  doing 
so  it  required  some  confidence  in  one's  diagnosis,  for  the  trocar  had  to 
be  made  to  penetrate  considerably  deeper  than  is  usually  necessary  in 
the  case  of  ovarian  cysts  which  lie  close  behind  the  abdominal  wall. 
A  quart  or  more  of  horribly  stinking  putrid  serum  escaped,  so  that  we 
suspected  there  had  been  a  perforation  of  the  intestine  into  the  perito- 
neum as  the  cause  of  the  inflamipation.  The  entire  disappearance  of 
the  tumor  and  recovery  of  the  patient  lent  confirmation  to  the  diag- 
nosis arrived  at.  In  encysted  dropsy  the  serum  drawn  off  will  coagu- 
late by  heat,  or  sometimes  without. 

Encysted  dropsy  may  also  exist  as  a  reliquium  of  retro-uterine 
haematocele. 

Encysted  peritoneal  abscess  may  simulate  ovarian  dropsy.  Thus  a 
case  was  recently  admitted  under  my  care  at  St.  Thomas's,  in  which  a 
tense,  obscurely-fluctuating  tumor  was  traced  from  the  right  side  of 
the  pelvis,  rising  as  high  as  the  umbilicus,  and  passing  the  median 
line  to  the  left.  The  uterus  was  three  and  a  half  inches  long ;  its 
fundus  deflected  to  the  left  by  the  swelling  in  the  right  of  the  pelvis ; 
the  cervix  was  pushed  forward  near  the  pubes.  In  the  fundus  of  the 
vagina,  on  the  right  of  the  cervix  uteri,  was  a  tense,  stretched,  elastic, 
smooth  depression.  The  tumor  had,  the  patient  said,  all  formed  within 
a  month.  Its  onset  was  not  marked  by  any  acute  symptoms.  But 
when  admitted  there  were  signs  of  irritative  fever;  the  pulse  was  about 
100,  the  temperature  ranged  from  100°  Fahr.  to  104°  Fahr.  The 
physical  signs  could  hardly  be  distinguished  from  those  of  ovarian 
tumor ;  but  the  rapidity  of  formation,  and  the  signs  of  irritative  fever, 
pointed  to  the  diagnosis  of  a  perimetric  abscess.  I  accordingly  punc- 
tured by  the  vagina  with  the  aspirator-trocar.  Fifty-eight  ounces  of 
ofi^ensive  pus  were  drawn  off;  the  tumor  subsided,  and  the  uterus  re- 
turned to  its  normal  position.  More  pus  formed,  which  w^as  again 
drawn  off.  The  woman  died  of  peritonitis  and  septicaemia.  The 
diagnosis  was  verified,  in  so  far  that  an  encysted  abscess  was  found. 
But  a  small  ovarian  cyst,  which  appeared  to  have  ruptured,  was  im- 
bedded in  the  abscess. 

In  connection  with  ovarian  cysts  it  is  desirable  to  refer  to  certain 
cysts  occasionally  found  on  the  external  surface  of  the  uterus,  and 
described  by  Huguier.  Two  cases  he  described  were  the  result  of 
metro-peritonitis.  Dr.  Matthews  Duncan,  in  his  work  on  "  Perime- 
tritis and  Parametritis,"  describes  "  an  example  in  the  autopsy  of  a  case 
of  ordinary  cancer  of  the  neck  of  the  uterus,  where  two  little  serous 
bags  of  the  size  of  hazelnuts  were,  without  adhesions,  lying  in  Doug- 
las's pouch  attached  to  the  lower  part  of  the  posterior  wall  of  the 
uterus  by  a  base  narrower  than  the  breadth  of  the  cysts  at  their  middle 


320  OVAEIAN    TUMORS. 

parts."  I  have  seen  several  similar  examples,  mostly  in  connection 
with  malignant  disease,  and  where  obvious  indications  of  recent  or  old 
peritonitis  existed.  I  have,  however,  seen  other  examples  of  cysts 
containing  serum  seated  on  the  peritoneal  surface  of  the  uterus,  on  the 
broad  ligaments  and  ovaries,  in  which  association  with  inflammation  or 
cancer  could  not  be  proved.  Dr.  McClintock  also  has  referred  to  cysts 
behind  the  uterus. 

Another  form  of  ascites  is  that  which  attends  upon  malignant  disease 
inducing  peritonitis.  Here  the  evidence  of  malignant  disease  will 
commonly  be  marked ;  and  we  shall  miss  the  characteristic  signs  of 
encysted  dropsy. 

It  is  the  complication  of  ascites  with  ovarian  cystic  disease  which  is 
so  often  puzzling.  If  the  ovarian  tumor  be  small,  and  the  ascitic  col- 
lection large,  the  tumor  is  easily  overlooked.  On  the  other  hand,  if 
the  tumor  be  large  and  the  ascitic  collection  small,  the  tumor  alone 
may  attract  attention.  In  the  latter  case  the  practical  consequences  of 
mistake  may  not  be  serious,  because  the  ovarian  tumor  is  the  disease 
that  rules  the  choice  of  treatment,  the  ascites  being  secondary.  In  the 
first  case,  if  there  be  urgent  distress  from  accumulation  of  fluid,  tap- 
ping by  the  aspirator-trocar  would  be  indicated ;  and  then,  the  fluid 
removed,  the  tumor  would  come  under  manipulation. 

i.  Are  there  adhesions  f  This  is  often  an  exceedingly  difficult  point 
to  determine.  I  have  seen  extensive  adhesions  where  it  was  confidently 
foretold  that  there  were  none.  Accurate  diagnosis  is  not  so  important  as 
it  was  at  one  time  thought  to  be.  Abundant  experience  has  now  proved 
that  moderate  adhesions  offer  no  serious  difficulty  in  carrying  out  ex- 
tirpation, and  do  not  jeopardize  the  recovery.  Mr.  Wells  says  his 
results,  in  cases  where  there  are  adhesions,  are  as  good  as  in  those 
where  there  are  none ;  and  that,  therefore,  practically  in  determining 
whether  ovariotomy  should  be  performed  or  not,  adhesions  to  the  ab- 
dominal wall  may  be  altogether  disregarded.  Extensive  and  intimate 
adhesions,  especially  to  the  lower  surface  of  the  liver,  to  the  intestines, 
and  to  the  pelvic  cavity,  will  sometimes  altogether  frustrate  the  opera- 
tion, or  the  injury  inflicted  in  overcoming  them  may  be  so  great  as  to 
prove  fatal.  But  adhesions  at  these  points  cannot  be  diagnosed,  so 
that  in  practice  we  are  often  compelled  to  disregard  the  possibility  of 
their  presence.  We  can  but  abandon  the  pursuit  of  extirpation,  when 
the  operation  having  been  begun,  it  is  found  that  the  adhesions  are  in- 
surmountable without  undue  violence. 

The  tumor  may  be  presumed  to  be  free  from  adhesions  if — 

1 .  There  be  no  history  of  antecedent  severe  pain  pointing  to  attacks 
of  peritonitis.     But  this  cannot  be  trusted. 

2.  If  we  can  pinch  up  folds  of  the  abdominal  wall,  or  make  the  ab- 
dominal wall  slide  over  the  tumor. 

3.  By  inspection  in  the  semi-prone  position,  watching  the  effect  of 
respiration,  if,  on  inspiration,  the  tumor  is  seen  to  glide  downwards 
beneath  the  alDdominal  wall,  and  to  glide  up  again  on  expiration. 

4.  If  on  moving  the  patient,  first  to  one  side  then  to  the  other,  the 
tumor  be  seen  or  felt  to  fiill  to  the  dependent  side. 


DIAGNOSIS.  321 

5.  If  the  uterus  move  freely  under  examination  by  finger  and  sound,, 
the  presumption  is  against  pelvic  adhesions. 

6.  If  we  can  make  out  a  thin  layer  of  ascitic  fluid,  giving  a  wave 
superficial  to  the  tumor,  we  have,  perhaps,  the  best  evidence  of  absence 
of  adhesions. 

7.  Adhesions  are  less  likely  to  be  present  if  the  tumor  is  benign  ; 
more  likely  if  the  tumor  is  malignant. 

Owing  to  the  free  peristaltic  and  other  movements  of  the  small  in- 
testines, adhesion  of  them  to  the  ovary  is  comparatively  rare. 

All  the  signs  of  free  movement  of  the  tumor  may  be  found,  and  yet 
there  may  exist  extensive  adhesions.  These  may  have  become  gradually 
drawn  out  by  the  advancing  growth  of  the  tumor,  have  become  elon- 
gated, partly  atrophied,  so  as  to  admit  of  free  movement,  but  yet  to  give 
some  trouble  to  separate  when  an  attempt  at  extirpation  is  made. 

j.  Is  the  tumor  benign  or  malignant  f  In  seeking  to  determine  this 
question,  we  shall  derive  assistance  from  the  history,  aspect,  and  con- 
stitutional condition.  If  the  aspect  be  clear,  and  the  general  health 
not  impaired  beyond  what  can  be  attributed  to  the  mere  bulk  and  pres- 
sure of  the  tumor ;  if  there  be  free  fluctuation  ;  if  the  uterus  be  capable 
of  being  isolated  from  the  tumor ;  if  we  find  the  tumor  free  from  ad- 
hesions, it  may  be  presumed  that  the  tumor  is  benign. 

It  is  not  easy,  however  free  and  universal  the  fluctnation  may  be,  to 
predicate  that  the  tumor  is  monocystic.  Indeed,  monocystic  tumors 
are  so  rare  that  it  is  scarcely  worth  while  to  contemplate  the  probability 
of  any  given  tumor  being  of  this  kind.  It  is  almost  always  a  safe 
prophecy  to  say  that  it  is  polycystic.  A  single  cyst  will,  ex  necessitate 
rei,  be  perfectly  uniform  on  its  surface,  and  of  spherical  or  ellipsoid 
form.  Deviations  from  these  characters,  or  variations  in  degree  of 
fluctuation,  or  in  the  rate  of  growth  in  different  parts,  are  conclusive 
against  a  single  cyst. 

The  tamor  is  probably  malignant,  if  it  have  grown  rapidly ;  if  the 
aspect  be  earthy,  sallow,  and  of  characteristic  malignant  cachexia ;  if 
emaciation  be  very  great ;  if  very  irregular,  knobby  in  form ;  if  the 
uterus  be  found  fixed  to  it ;  if  irregular  protrusions  be  found  behind 
the  uterus;  if  on  rectal  examination — which  should  never  be  omitted 
where  malignancy  is  suspected — these  projections  into  the  rectum  be 
more  plainly  felt ;  if  the  vaginal  or  other  glands  within  observation  be 
enlarged  and  hardened ;  if  there  be  any  considerable  amount  of  ascitic 
fluid,  and  especially  if  there  be  oedema  of  the  legs,  with  or  without  phleg- 
masia dolens. 

The  recognition  of  ovarian  tumor  in  the  earliest  stage  is  especially  dif- 
ficult. Very  little  distress  may  attend  the  early  growth.  Practically, 
it  rarely  happens  that  the  case  comes  before  us  until  a  tumor  of  consid- 
erable size  has  formed.  The  first  inconvenience  that  attracts  attention 
is  the  increased  size  of  the  abdomen ;  and  this  is  often  more  annoying 
for  moral  than  for  physical  reasons.  An  unmarried  woman  is  visibly 
increasing  in  size,  and  censorious  people  whisper  away  her  character ; 
and  if  dependent  upon  her  own  exertions,  she  is  unable  to  find  employ- 
ment. But  sooner  or  later  physical  distress  from  pressure  is  pretty 
sure  to  follow. 

21 


322  OVARIAN    TUMORS. 

When  a  small  cyst  containing  fluid  has  formed,  we  may  feel  a  smooth, 
rounded,  tense  body  stretching  the  roof  of  the  vagina  on  one  side  of  the 
cervix,  or  a  little  behind.  Small  cysts  get  into  Douglas's  pouch,  caus- 
ing some  amount  of  prolapse  of  the  vagina.  By  bimanual  palpation 
we  may  possibly  define  the  tumor,  and  even  make  out  fluctuation.  In 
this  stage,  a  cystic  ovary  may  be  mistaken  for  a  Fallopian  gestation,  or 
a  dropsy  of  the  tube.  In  either  event  the  uterus  may  be  so  pushed  for- 
wards by  the  tumor  as  to  obstruct  the  bladder  and  cause  retention  of 
urine,  as  in  the  following  case:  A  young  woman  applied  as  an  out- 
patient, complaining  of  retention  of  urine.  In  accordance  with  our 
practice  in  such  cases,  she  was  at  once  sent  to  bed.  I  found  the  os  uteri 
pressed  close  behind  the  symphysis  pubis  :  after  drawing  off  the  urine  I 
passed  the  sound  into  the  uterus ;  it  went  in  the  normal  direction  forwards, 
and  the  fundus  was  felt  just  above  the  symphysis.  This  made  it  clear 
that  the  uterus  of  normal  size  was  pushed  bodily  forwards  by  something 
behind  it.  Exploring  with  the  finger  to  the  sides  of,  and  behind,  the 
uterus,  the  vaginal  roof  was  felt  stretched  out,  and  a  tense,  elastic,  de- 
fined swelling  with  fluctuation  was  made  out  by  vagino-abdominal 
touch.  The  swelling  did  not  rise  above  the  pelvic  brim,  and  except 
bv  the  two-handed  mode  of  examination  it  could  hardly  have  been 
distinguished.  I  concluded  that  it  was  an  incipient  ovarian  cystic 
tumor ;  and  since  it  was  causing  serious,  even  dangerous,  pressure  upon 
the  bladder,  I  punctured  it  through  the  roof  of  the  vagina  by  the 
aspirator-trocar,  and  drew  off  about  six  ounces  of  limpid  lemon-colored 
serum.  The  uterus  then  retreated  to  near  the  centre  of  the  pelvis, 
leaving  the  bladder.  No  bad  symptom  followed ;  but  after  some  days 
there  was  again  retention  ;  the  uterus  was  again  pushed  forwards  against 
the  pubes.  I  repeated  the  operation,  this  time  drawing  off  about  two 
ounces  of  fluid,  and  injected  an  ounce  of  tincture  of  iodine,  hoping  that 
a  cyst  so  small  might  contract  and  be  cured.  For  a  time  the  patient 
seemed  to  be  doing  well ;  but  irritative  fever  set  in,  and  ended  fatally. 
Unfortunately  a  post-mortem  examination  could  not  be  made.  We 
have  since  had  another  case  in  the  hospital  of  retention  of  urine  caused 
by  a  small  ovarian  tumor. 

Difficulty  of  diagnosis  between  early  cystic  tumor  of  ovary,  tubal 
gestation,  and  dropsy  of  the  Fallopian  tube,  is  the  less  to  be  regretted, 
because  puncture  by  the  aspirator-trocar  is  probably  the  best  treatment 
in  all  these  cases. 

A  rare  instance  of  difficult  diagnosis  arose  in  a  case  related  by  Disse 
{Monatsschrift  fur  Geburtskmide,  1857),  in  which  an  ovarian  cyst  formed 
part  of  a  femoral  hernia. 

Puncture  by  the  aspirator  or  needle-trocar  should  be  preferred  in  all 
cases  where  the  prevailing  character  of  the  tumor  is  solidity,  and  where 
the  fluctuation  is  obscure  and  limited. 

The  fluid  drawn  off  should  be  carefully  examined.  It  sometimes 
gives  diagnostic  evidence.  Spencer  Wells  says,  in  the  case  of  uterine 
tumor,  it  is  not  the  viscid  mucoid  fluid  of  multilocular  ovarian  disease, 
but  a  thin  serum  containing  5,  10,  or  15  per  cent,  of  blood  intimately 
mixed  with  it. 

If  we  get  fluid  of  this  character  or  none,  the  idea  of  gastrotomy  should 


DIAGNOSIS.  323 

be  abandoned,  unless,  indeed,  we  are  prepared  to  undertake  the  extir- 
pation of  the  uterus. 

It  will  be  convenient  to  discuss  the  therapeutical  value  of  tapping 
and  of  iodine  injections,  whilst  we  are  discussing  the  diagnostic  value 
of  tapping. 

Tapping  and  Exploratory  Incisions. — After  exhausting  all  ordinary- 
diagnostic  methods,  the  indication  to  relieve  from  distressing  symptoms 
and  danger  to  life  may  still  be  so  urgent  that  we  are  justified  in  resort- 
ing to  certain  operations  in  order  to  attain  the  precise  knowledge  nec- 
essary to  direct  ulterior  proceedings.  These  operations  are  tapping  and 
exploratory  incisions. 

Tapping  is  indeed  an  operation  of  old  standing ;  for  long  it  was  the 
only  proceeding  employed  to  relieve  the  distension  and  other  urgent 
symptoms.  The  operation  was  looked  upon  simply  as  a  palliative,  and 
occasionally  it  turned  out  to  be  curative.  Now  there  is  added  to  its 
palliative  value  a  diagnostic  element.  When  a  tumor,  apparently 
raonocystic,  is  emptied  of  the  greater  proportion  of  its  fluid,  the  cyst 
which  contained  this  fluid  collapses,  and  the  operator  can  press  his  hand 
down  upon  the  base  of  the  tumor  and  feel  what  remains.  Sometimes, 
but  rarely,  we  may  feel  nothing;  the  tumor  has  to  all  evidence  gone. 
In  these  cases  the  doubt  is  reasonable  that  the  cyst  was  not  ovarian, 
but  a  simple  cyst  of  the  broad  ligament.  In  such  a  case  the  tapping 
may  prove  curative  as  well  as  diagnostic.  The  cyst-walls  may  shrivel 
up,  cease  to  secrete,  and  finally  become  atrophied.  It  is  in  such  cases 
that  the  injection  of  iodine  is  likely  to  be  followed  by  cure ;  and  it  must 
often  remain  doubtful  whether  the  iodic  injection  was  not  superfluous. 
Or  we  come  to  the  conclusion  that  there  is  no  cyst  at  all ;  that  the  case 
is  one  of  ascites.  The  peritoneum  emptied,  we  can  now  examine  the 
state  of  the  liver  and  other  abdominal  viscera  more  easily  ;  we  may  find 
tubercular  or  other  disease  of  the  lumbar  and  pelvic  glands. 

It  is  not  always  easy  to  determine  that  there  is  no  cyst.  Its  walls 
may  be  so  thin,  and  be  adherent  to  the  abdominal  wall,  that  incision 
may  go  through  the  cyst- wall  without  this  being  identified. 

In  other  cases,  and  these  by  far  the  most  numerous,  when  fluid  ceases 
to  run  by  the  canula,  we  come  down  to  a  residual  tumor  more  or  less 
solid,  more  or  less  bulky.  If  there  remain  a  considerable  mass  bulging 
up  behind  the  abdominal  wall  on  one  side,  or  near  the  pelvis,  and  pre- 
senting fluctuation,  we  may  diagnose  another  cyst,  and  the  trocar  may 
be  used  to  puncture  this,  and  even  another  in  succession,  or  we  may 
explore  through  the  canula  by  a  sound  to  ascertain  the  condition  of  the 
tumor.  Here  the  polycystic  character  is  beyond  .doubt.  And  the 
therapeutical  conclusion  may  confidently  be  drawn  that  neither  by 
iodine  injection  nor  by  any  means,  short  of  extirpation,  will  a  cure  be 
obtained.  In  these  cases  the  fluid  isoft^n  gummy  or  colloid,  sometimes 
puriform.  Once  opened,  these  tumors  are  liable  to  run  a  rapid  down- 
ward course.  Suppuration  in  the  cysts  is  very  likely  to  occur.  Injec- 
tion of  iodic  or  other  irritants  will  only  accelerate  mischief.  The  prac- 
ticability of  extirpating  the  mass  should  be  earnestly  considered. 

In  another  class  of  cases,  also  numerous,  when  the  .fluid  ceases  to  run, 
the  great  bulk  of  the  swelling  has  disappeared.     But  by  deep  pressure 


324  OVARIAN    TUMORS. 

through  the  now  flaccid  abdomen,  we  come  upon  a  solid  residuum  in 
the  pelvis,  which  may  sometimes  be  grasped  in  the  hand,  and  which 
may  always  be  defined  between  the  hand  outside  and  a  finger  in  the 
vagina.  In  these  cases  also  it  is  of  no  use  to  inject  iodine.  The  solid 
residuum  almost  certainly  contains  smaller  cysts,  whose  development, 
repressed  by  the  preponderant  activity  of  the  one  which  has  been  emp- 
tied, will  quickly  take  its  place,  if  indeed  the  first  cyst  do  not  fill  again. 
When  the  tumor  has  thus  grown  again,  it  is  generally  advisable  not  to 
repeat  the  tapping,  but  to  proceed  to  extirpation,  which  holds  out  the 
only  trustworthy  hope. 

Exploratory  Incision. — Before  proceeding  to  this  measure,  the  call 
for  relief  should  be  so  serious  as  to  justify  extirpation,  should  this 
ultimatum  be  found  practicable.  Exploratory  incisions  are  not,  it  is 
true,  so  dangerous  as  the  major  operation;  but  a  fatal  issue  has  with 
considerable  frequency  occurred.  It  properly  claims  consideration 
when  other  means  of  diagnosis,  including  puncture  or  tapping,  yield 
no  results,  or  are  contraindicated.  It  is  generally  advisable  on  begin- 
ning the  operation  to  have  all  things  prepared  for  proceeding  to  extir- 
pation. The  patient  should  be  in  anaesthesia.  A  small  incision,  an  inch 
or  two  long,  is  made  with  a  bistoury,  midway  between  the  umbilicus 
and  pubes.  This  is  very  cautiously  made,  so  as  to  avoid  all  risk  of 
incising  the  tumor,  which  may  not  be  ovarian.  The  incision  should 
be  just  large  enough  to  admit  the  finger  to  feel  the  tumor,  and  to  sweep 
round  in  a  short  radius,  so  as  to  ascertain  if  there  are  adhesions.  This 
will  generally  be  large  enough  also  to  enable  one  to  inspect  the  surface 
of  the  tumor..  The  uterus,  or  uterine  fibroid,  presents  a  dark-reddish 
fleshy  appearance,  which,  if  not  absolutely  difterential  from  the  usual 
pearly-blue  aspect  of  an  ovarian  cyst,  should  serve  as  a  warning  not  to 
proceed  to  ulterior  measures  without  further  investigation. 

For  clinical  purposes,  Kiwisch,  Scanzoni,  and  Hutchinson  divide 
tumors  of  the  ovary  into  two  classes,  namely,  those  which  contain 
cavities,  and  those  which  form  solid  and  compact  masses.  To  the  first 
belong  the  simple  or  multiple  cysts,  the  cysto-sarcoma,  the  colloid 
tumor,  and  the  cysto-careinoma ;  whilst  the  second  comprises  the  fibroid 
bodies,  the  enchondromata,  and  the  cancerous  tumors  without  cavities. 
This  division  is  certainly  useful.  But  there  is  another  division  which, 
not  displacing  this  one,  I  think  is  even  more  useful  in  practice.  Ova- 
rian tumors  may  be  divided  into  benign  and  malignant.  It  is  not 
indeed  easy  in  all  cases  to  tell,  in  the  living  subject,  to  which  class  a 
particular  tumor  belongs.  But  in  many  cases  we  can  form  a  reason- 
ably good  opinion.  For  example,  we  may  often  negative  malignancy. 
When  we  can  do  this  the  course  of  treatment  to  adopt  is  more  easily 
decided,  and  the  prognosis  is  more  hopeful.  On  the  other  hand,  we 
can  often  affirm  malignancy ;  and  in  this  case  we  know  the  treatment 
must  be  more  circumspect,  and  the  prognosis  be  more  grave. 

h.  Two  other  conditions,  which  may  possibly  give  rise  to  error,  are 
distension  of  the  bladder  Mdth  urine,  and  fecal  accumulation. 

The  error  of  overlooking  a  distended  bladder  will  be  avoided,  if  the 
rule  of  passing  the  catheter  before  proceeding  to  abdominal  examina- 
tion be  observed. 


TAPPING.  325 


CHAPTER  XXXIII. 

TREATMENT  OF  OVARIAN  CYSTIC  DISEASE:    MEDICINAL; 
TAPPING  BY  VAGINA,  AND  BY  ABDOMEN. 

The  experience  of  a  century  has  but  confirmed  the  conclusion 
arrived  at  by  William  Hunter,  that  ovarian  dropsy  was  an  incurable 
aflPection,  and  that  tapping  was  the  only  palliative. 

The  methods  by  which  nature  or  accident  effects  spontaneous  cure 
of  ovarian  dropsy  are  so  uncertain  in  their  result,  and  so  unforeseen, 
that  the  expectation  of  seeing  relief  occur  in  this  way  cannot  influence 
the  conduct  of  the  surgeon.  Rupture,  perforation,  or  twisting  of  the 
tumor  may,  indeed,  effect  a  cure ;  but  they  are  far  more  likely  to  cause 
death. 

It  may  with  confidence  be  said  that  if  a  woman  is  to  be  rescued  from 
the  dangers  of  an  ovarian  tumor,  the  only  reasonable  prospect  lies  in 
extirpation. 

The  following  are  the  proceedings  for  the  treatment  of  ovarian  cystic 
tumor  which  especially  call  for  discussion  : 

1.  Medicinal. — The  Pharmacopceia  has  been  ransacked  in  vain. 
There  is  no  trustworthy  evidence  that  any  internal  remedy  has  the 
slightest  effect  in  arresting  the  growth  of  an  ovarian  cyst.  If,  in  a  few 
instances,  a  cyst  have  seemed  to  diminish  or  to  disappear  under  bro- 
mides, iodides,  chlorates,  or  other  medicines,  further  trials  in  other 
cases  have  signally  failed.  Dr.  Peaslee  "  has,  however,  in  several  in- 
stances of  late  apparently  arrested  the  growth  of  ovarian  cysts  in  the 
early  stages  by  the  application,  per  vaginam,  of  ointment  of  iodide  of 
lead.  But,"  he  adds,  "further  trials  must  demonstrate  how  permanent 
is  to  be  the  benefit  thus  obtained." 

Although  the  surgical  proceedings  which  have  successively  been 
tried  for  the  relief  or  cure  of  ovarian  cystic  tumors  have  yielded  for  the 
most  part  only  unsatisfactory  results,  a  brief  review  even  of  those  which 
have  most  unequivocally  failed  is  useful.  In  the  first  place,  this  review 
may  save  us  from  repeating  operations  which  experience  has  con- 
demned. In  the  second  place,  these  proceedings  may  be  regarded  as 
experiments  calculated  to  give  us  useful  knowledge  as  to  the  constitu- 
tion and  behavior  of  cystic  tumors.  Thirdly,  some  of  these  proceed- 
ings, although  they  have  lost  claim  to  be  regarded  as  generally  appli- 
cable, may  still  prove  valuable  in  exceptional  cases. 

2.  Surgical. — Tapping  and  iodic  injections  have  to  some  extent  been 
discussed  under  "  Diagnosis."  Many  simple  cysts  may  be  cured  by 
simple  tapping,  or  by  tapping  and  injection  of  iodine.  The  difficulty 
is  to  determine  whether  a  cyst  be  simple  or  compound.  Sometimes 
tapping  itself  proves  fatal.  It  is  of  course  less  hazardous  than  ovari- 
otomy, but  it  is  not  free  from  danger.     In  the  great  majority  of  cases . 


326  OVARIAN    TUMORS. 

the  cyst  will  quickly  fill  again ;  and  the  operation  must  be  repeated. 
Sometimes  tapping  is  followed  by  inflammation  and  suppuration  of 
the  tumor.  And  although  tapping  will  commonly  give  immediate 
comparative  relief,  it  has  been  thought  that  the  disease  is  often  acceler- 
ated by  it. 

Tapping  hy  the  Vagina. — The  argument  for  this  proceeding  rests 
upon  the  anatomical  fact,  that  the  ovary  always  occupies  the  lowest 
position  in  the  pelvis.  It  is  in  direct  relation  with  the  roof  of  the 
vagina,  and  below  the  intestines.  A  fair  amount  of  success  has  at- 
tended the  operation;  but  there  is  not  sufficient  reason  to  conclude  that 
it  is  more  favorable  than  tapping  by  the  abdomen. 

There  are  two  forms  of  tapping:  the  one  is  simple  tapping;  in  the 
other  the  tapping  is  supplemented  by  other  proceedings,  as  keeping  the 
cyst  open,  and  throwing  irritant  or  other  fluids  into  the  cyst. 

Simple  tapping  consists  in  puncturing  the  cyst,  letting  the  fluid  con- 
tents drain  off,  and  then  letting  the  opening  close.  This  proceeding 
may  be  adopted  as  a  palliative,  with  a  view  to  cure ;  or  as  tentative 
with  a  view  to  obtaining  information  to  guide  further  treatment.  It 
is  useful  only  in  a  limited  order  of  cases.  Our  first  care  then  is  selec- 
tion. The  favorable  conditions  are :  a  small  "cyst  which  descends  fairly 
behind  the  uterus,  bulging  out  the  posterior  wall  and  roof  of  the  vag- 
ina ;  distinct  fluctuation ;  absence  of  solid  masses  at  the  most  promi- 
nent point  where  puncture  must  be  made. 

The  cases  in  which  vaginal  tapping  is  most  likely  to  be  useful  are 
the  monocystic.  But  this  condition  can  hardly  be  determined  before 
tapping;  and  thus  tapping  comes  to  be  experimental  as  regards  treat- 
ment, and  exploratory  as  aiding  diagnosis.  I  would  therefore  strongly 
advise  that  the  first  or  diagnostic  tapping  be  made  by  the  aspirator- 
trocar.     Comparatively  little  risk  attends  this  method. 

The  Operation. — No  matter  what  the  instrument  employed  for  tap- 
ping, the  chief  difficulty,  of  course,  consists  in  selecting  the  point  for 
puncture.  This  should  be  determined  with  precision.  The  cyst,  it  is 
assumed,  occupies  by  its  most  dependent  part  the  peritoneal  sac  between 
the  uterus  and  rectum.  Occupying  this  space,  it  causes  the  uterus  and 
rectum  to  diverge,  the  uterus  is  pushed  forwards  and  a  little  to  one  side, 
the  rectum  is  compressed  or  flattened  backwards.  The  perforating  in- 
strument must  therefore  strike  between  these  two  organs.  First,  pass 
a  catheter  into  the  bladder,  to  empty  this  organ,  to  insure  its  safety,  to 
remove  it  from  all  interference,  by  collapsing.  Secondly,  feel  for  the 
position  of  the  uterus  by  touch  and  by  the  sound.  In  front  of  the  os 
uteri  through  the  anterior  vaginal  wall,  we  may  feel  the  body  of  the 
uterus ;  by  passing  the  sound,  the  position  and  relations  of  the  uterus 
are  made  still  more  clear.  This  is  one  great  landmark.  We  must  keep 
behind  this.  Thirdly,  pass  the  forefinger  into  the  rectum,  the  sound 
being  still  in  the  uterus.  You  will  then  ascertain  the  position  and  re- 
lations of  the  rectum  at  the  level  of  the  tumor  and  os  uteri.  There 
will  probably  be  a  space  of  one  or  two  inches  or  more  between  the  os 
uteri  and  the  anterior  wall  of  the  rectum.  It  is  within  this  space  that 
the  puncture  must  be  made.  The  anterior  wall  of  the  rectum  is  the 
other  great  landmark.     Fourthly,  your  finger  quits  the  rectum  and 


TAPPING    BY     VAGINA.  327 

returns  to  the  roof  of  tlie  vagina  behind  the  cervix  uteri ;  tlien,  feel- 
ing the  cyst  here,  press  firmly  down  towards  it  the  cyst  from  above  by 
your  other  hand  in  the  abdominal  wall  above  the  pubes.  You  thus 
get  evidence  of  a  fluctuating  point.  Tapping  being  resolved  upon, 
you  place  the  patient  in  position.  It  is  scarcely  desirable  to  give  chlo- 
roform. The  lithotomy  position  is  very  convenient ;  but  it  is  often 
quite  as  easy  to  operate,  the  patient  lying  in  bed  on  her  left  side,  the 
nates  drawn  well  to  the  edge.  An  assistant  presses  the  tumor  firmly 
down  into  the  pelvis ;  the  forefinger  resting  on  the  tumor  an  inch  or  so 
behind  the  cervix  uteri  guides  the  trocar,  which  is  thrust  in  perpen- 
dicularly to  the  surface,  and  carried  in  the  direction  of  the  axis  of  the 
pelvis  for  about  an  inch,  or  until  the  sense  of  resistance  is  suddenly  lost. 
Then,  the  fluid  ought  to  flow  either  spontaneously,  or  under  the 
vacuum  produced  by  the  pump.  The  exhausting  pressure  should  be 
kept  up  as  long  as  fluid  flows.  Then  explore  to  ascertain  what  remains 
of  the  tumor.  Withdraw  the  trocar.  Enough  has  been  done  for  the 
occasion.  Time  must  be  allowed  to  observe  the  subsequent  course  of 
events,  before  the  diagnosis  can  be  absolute,  and  before  determining  on 
further  operations. 

As  yet  we  cannot  be  certain  that  the  cyst  is  not  formed  by  a  tubal 
gestation,  or  by  dropsy  of  the  Fallopian  tube.  In  either  of  these  cases 
it  would  not  be  desirable  to  enlarge  the  opening  or  to  inject  fluid  into 
the  cyst.  Simple  exhaustion  of  the  fluid  contents  may  be  sufficient  for 
cure  of  either  of  these  affections,  and  also  of  a  simple  cyst  of  the  ovary 
or  of  the  broad  ligament.  It  is  obviously,  then,  sound  practice  to  take 
the  benefit  of  this  possibility  of  cure. 

If  the  cyst  be  ovarian  it  will  probably  fill  again.  By  repeated 
tapping  by  vacuum,  a  small  ovarian  cyst  may  gradually  become  smaller, 
shrivel  up,  and  be  obliterated.  This  process  may  be  accejerated  by 
iodine  injection.  A  few  drachms  may  be  turned  on  w^hen  the  cyst  has 
been  emptied. 

Firm  pressure  by  compress  and  binder  should  be  applied  imme- 
diately after  operation,  and  sustained  for  some  days.  The  double  use 
of  this  is  to  obviate  the  vacuum  that  might  otherwise  form,  favoring 
suction  of  air  into  the  cyst ;  and  to  promote  the  reduction  of  the  cyst  by 
maintaining  its  walls  in  contact. 

Rest  in  bed  for  a  week,  salines  and  sedatives  are  to  be  recommended 
as  after-treatment. 

If,  aided  by  this  preliminary  tapping,  the  tumor  be  found  to  be  ova- 
rian, and  be  of  the  size  of  a  foetal  head,  or  somewhat  larger,  we  may 
then  consider  the  expediency  of  tapping  by  the  vagina,  and  keeping 
the  cyst  open,  so  as  to  allow  continuous  drainage  to  go  on.  The  pre- 
paratory steps  are  the  same  as  those  already  described.  It  is  best  to 
use  a  long  curved  trocar,  after  the  manner  of  Kiwisch.  The  canula  is 
connected  with  an  elastic  drainage-tube,  to  carry  off  the  fluid.  The 
next  step  is  to  widen  the  orifice.  To  do  this  a  long  director,  correspond- 
ing exactly  to  the  curve  of  the  canula,  is  passed  through  the  canula  as 
deeply  into  the  cyst  as  it  will  go.  The  canula  is  then  withdrawn,  and 
a  long  probe-pointed  bistoury  is  guided  along  the  director  into  the 
cavity.     By  this  the  wound  is  enlarged,  to  allow  the  forefinger  to  pass 


328  OVARIAN     TUMORS. 

into  the  collapsing  sac,  to  ascertain  the  condition  of  the  internal  surface. 
On  withdrawing  the  finger,  a  long  curved  uterine  tube  is  inserted  into 
the  opening,  so  as  to  project  well  into  the  cavity,  and  its  outer  end  is 
fastened  with  a  T-bandage  in  front  of  the  pubes.  The  uterine  tube 
should  be  furnished  with  a  flexible  tube,  to  drain  off  into  a  convenient 
vessel.  This  vessel  should  always  contain  water  enough  to  cover  the 
open  mouth  of  the  tube.  This  will  prevent  the  sucking-in  of  air  into 
the  cyst.  On  the  second  or  third  day,  symptoms  of  inflammation  of 
the  cyst,  with  severe  reaction,  commonly  set  in.  A  discharge  of  ichor- 
ous fluid  takes  place,  and  there  is  great  pain  in  the  pelvic  region.  In 
favorable  cases,  says  Kiwisch,  these  symptoms  gradually  gave  Avay  to 
a  purulent  discharge,  which  ceased  in  from  five  to  seven  weeks,  and 
then  shrivelling  and  perfect  obliteration  of  the  cyst  took  place.  As 
long  as  any  secretion  goes  on  it  is  desirable  to  inject  lukewarm  water 
through  the  tube  twice  a  day. 

Scanzoni'  is  an  advocate  for  vaginal  tapping,  in  preference  to  ab- 
dominal tapping,  generally,  when  the  cyst  can  be  reached  by  the  vagina, 
amongst  other  reasons,  because  it  secures  more  perfect  draining  of  the 
cyst.  If  this  could  be  always  performed,  he  says,  abdominal  tapping 
would  disappear  from  the  rank  of  recognized  operations.  Our  expe- 
rience of  this  method  is,  perhaps,  insufficient.  But  it  is  certain  that 
the  advantages  of  it  are  not  without  a  drawback  of  danger  and  of  failure. 
There  is  always  an  element  of  uncertainty,  owing  to  the  varying  char- 
acter of  these  tumors,  complications,  and  the  idiosyncrasy  of  the  patient. 
The  operation  is,  therefore,  of  an  experimental  kind.  The  inflamma- 
tion, the  suppuration,  may  extend  beyond  the  wished-for  limits.  Then 
there  is  an  objection  which  especially  applies  to  tapping  through  the 
vagina.  The  wound  is  necessarily  made  at  the  base  of  the  tumor,  where 
solid  elements  are  most  commonly  found,  and  where  the  bloodvessels 
which  feed  the  tumor  are  largest  and  most  abundant.  Kiwisch  him- 
self, the  chief  advocate  for  the  measure,  says  it  is  only  of  use  in  mod- 
erately-large simple  cysts,  because  in  very  large  cysts  the  extensive 
decomposition  must  be  very  exhausting  to  the  system,  and  compound 
cysts  do  not  allow  of  a  full  shrivelling-up  of  the  sac.  Now  here  is  the 
difficulty ;  we  can  rarely  be  certain  that  the  cyst  is  not  compound. 

Some  cases  are  related  by  Mr.  Wells.  His  conclusion  is,  that  "sim- 
ple tapping  is  more  hazardous  than  tapping  followed  by  drainage,  and 
that  drainage  should  be  so  complete,  that  no  reaccumulation  of  fluid 
can  take  place,  the  cavity  being  kept  open  until  the  walls  collapse  and 
unite,  so  that  it  is  completely  obliterated." 

I  am  disposed  to  qualify  this  view.  Assuming  that  only  those  cases 
are  suitable  for  vaginal  tapping,  in  which  there  is  strong  presumption 
that  the  cyst  is  single,  I  would  first  practice  a  simple  tapping;  and  if 
the  cyst  refilled  I  would  combine  the  second  tapping  with  drainage. 

Tavignot  proposed  tapping  by  the  rectum.  Where  the  tumor  pro- 
trudes more  within  reach  by  this  canal,  it  may  be  preferable  to  tapping 
by  the  vagina.  But  whilst  open  to  all  the  objections  urged  against 
tapping  by  the  vagina,  there  is  a  special  danger  attending  it,  from  the 

^  "  Maladies  des  Organes  Sexuels  de  la  Fenime."     French  ed.,  1858. 


TAPPING     BY    ABDOMEN.  329 

greater  likelihood  of  foul  air  getting  into  the  cyst  from  the  rectum. 
The  sphincter  ani  converts  the  rectum  into  a  pouch,  often  filled  with 
air,  and  may  even  by  its  contraction  help  to  force  air  into  the  cyst. 
And  dysenteric  tenesmus  has  been  caused  by  the  irritation  produced. 

Tajipivg  by  the  abdomen  is  an  operation  often  of  necessity  to  relieve 
urgent  distress  of  breathing.  It  scarcely  merits  the  rank  of  an  opera- 
tion of  election ;  since,  except  in  rare  and  unforeseen  cases,  it  is  at  best 
a  palliative  only.  But  as  a  palliative  it  is  exceedingly  valuable.  It  is 
applicable  to  a  large  class  of  cases,  and  especially  to  those  large  tumors 
which  are  admittedly  unfit  for  vaginal  tapping.  It  is  a  legitimate 
resource  in  most  cases  where,  for  any  reason,  extirpation  of  the  tumor 
is  excluded.  It  possesses  the  great  advantages  over  the  vaginal  opera- 
tion, that  it  is  easier  of  performance,  that  it  is  done  at  a  distance  from 
the  base  of  the  tumor,  so  that  we  are  more  likely  to  avoid  wounding 
solid  and  vascular  parts ;  that  tlrere  is,  further,  a  considerable  area  of 
space  within  which  we  can  select  the  point  for  puncture. 

The  following  dangers  attend  tapping  by  the  abdomen : 

1.  It  is  possible  to  wound  a  vessel  in  the  abdominal  wall  large 
enough  to  cause  serious  bleeding.  This  is  no  real  bar,  because  all 
serious  bleeding  may  be  avoided  by  selecting  the  linea  alba  for  piinc- 
ture,  and  by  dividing  the  skin  by  a  scalpel,  by  which  precaution  we 
can  secure  any  injured  vessel  before  plunging  in  the  trocar. 

2.  The  risk  of  wounding  some  large  vessel  in  the  wall  of  the  sac  is 
more  serious,  and  can  hardly  be  secured  against.  This  risk  is,  however, 
small  in  cysts  presumed  to  be  singl-e,  and  in  which  free  fluctuation  in- 
dicates that  the  walls  are  thin.  In  the  case  of  tumors  partly  solid,  and 
whose  walls,  even  at  the  fluctuating  parts,  are  thick,  the  risk  is  very 
great,  so  great  in  fact,  that  if  things  generally  are  not  adverse,  the 
major  operation  of  extirpation  should  be  at  once  preferred.  The  hem- 
orrhage is  dangerous  in  two  ways  :  blood  may  be  slowly  poured  out 
into  the  peritoneum,  setting  up  peritonitis;  or  it  may  pour  into  the 
cyst  to  such  an  extent  as  to  cause  augemia,  as  well  as  inflammation  of 
the  cyst.  If,  after  tapping  a  thick-walled  cyst,  symptoms  of  internal 
hemorrhage  arise,  the  operation  for  extirpation  should  be  immediately 
undertaken.  By  this  means,  and  only  by  this  means,  can  the  bleeding 
be  arrested  by  tying  the  pedicle,  and  the  effused  blood  be  removed. 

3.  The  rapid  emptying  of  the  cyst  may  be  followed  by  collapse,  just 
as  prostration  sometimes  follows  too  rapid  delivery.  This  is  our  reason 
for  compressing  the  abdomen  by  bandages  as  the  fluid  escapes. 

4.  Some  of  the  contents  of  the  cyst  may  run  into  the  peritoneal 
cavity  and  set  up  inflammation,  which  may  prove  fatal.  This  accident 
may  be  avoided  by  using  a  sharp  well-made  trocar,  by  dividing  the 
skin  of  the  abdomen  first  by  a  scalpel,  oiling  the  trocar,  and  piercing 
the  remains  of  the  abdominal  wall  and  the  cyst-wall  with  a  decided 
stab,  so  as  to  carry  the  canula  a  good  inch  or  more  through  into  the 
cavity  of  the  cyst,  before  withdrawing  the  trocar.  To  accomplish  this 
the  trocar  should  be  much  longer  than  the  old-fashioned  instruments. 

5.  Air  may  be  sucked  into  the  sac.  When  this  accident  happens, 
decomposition  and  suppuration  are  very  likely  to  ensue.  Irritative 
fever  will  set  in,  and  the  result  may  be  fatal.     This  risk  should  be 


330  OVARIAN    TUMORS. 

guarded  against  by  using  a  trocar  so  constructed  as  only  to  permit  flow 
from  the  cyst  outwards,  by  keeping  the  delivery  end  of  the  drainage 
tube  under  water,  and  by  steadily  following  down  the  emptying  sac 
by  pressure. 

6.  In  the  case  of  compound  cysts,  especially  if  malignant,  mere 
tapping,  where  precaution  against  letting  in  air  has  been  successful, 
may  be  still  followed  by  suppuration  and  fatal  septicaemia.  Indeed, 
in  most  cases,  it  is  observed  that  after  several  tappings  the  nature  of 
the  fluid  changes,  becoming  turbid,  more  viscid,  or  puriform.  Where 
evidence  of  suppuration  in  the  cyst  is  obtained,  the  feasibility  of  extir- 
pating the  tumor  should  be  considered. 

7.  By  repeated  tapping  the  system  is  exhausted  by  the  drain  caused 
by  the  diversion  of  material  to  the  cyst.  This  is  probably  often  in- 
creased by  tapping,  which  takes  off  the  pressure  that  restrained  ex- 
halation. 

Even  where  no  untoward  accidents  follow  tapping,  the  relief  obtained 
is  often  very  transient.  Fluid  rapidly  collects  again,  and  the  opera- 
tion must  be  very  soon  repeated.  It  has  been  supposed  that  tapping 
accelerates  the  progress  of  the  disease, — that  it  is,  in  fact,  the  beginning 
of  the  end ;  that,  once  performed,  the  necessity  for  having  recourse  to 
it  again  and  again  recurs  at  a  constantly  accelerated  ratio.  There 
appears  to  me  to  be  a  fallacy  lurking  under  this  belief.  Tapping  is 
rarely  performed  until  the  symptoms  are  so  urgent  that  relief  is  im- 
perative. This  implies  that  the  disease  is  in  high  activity,  and  that 
things  have  reached  a  climax.  From  this  time  it  is  not  surprising 
that  the  course  should  be  down-hill,  whether  tapping  be  performed  or 
not.  And  it  can  scarcely  be  doubted  that  in  most  cases,  tapping  does 
afford  a  respite  more  or  less  prolonged.  It  certainly,  in  some  cases, 
averts  apparently  imminent  death.  In  some  cases,  unforeseen,  it  must 
be  admitted,  it  is  followed  by  complete  cure. 

I  think  the  matter  may  be  summed  up  as  follows: 

Tapping  has  its  own  immediate  dangers,  but  these  are  limited  to  a 
small  proportion  of  cases;  tapping  postpones  death  from  the  secondary 
effects,  such  as  pressure  of  the  tumor  upon  the  viscera  and  bloodvessels, 
and  allows  the  sufferer  to  sink  under  the  })roper  effects  of  the  progress- 
ing disease. 

Even  simple  tapping,  then,  cannot  be  urged  upon  a  patient  as  an 
operation  free  from  danger.  A  considerable  proportion  of  patients  die 
very  quickly  after  its  performance. 

It  is  often  objected  that  tapping  lessens  the  chance  of  success  of 
ovariotomy,  should  this  operation  subsequently  be  performed.  This 
objection  is  not  borne  out  by  experience.  It  may  even  in  many  cases 
be  regarded  as  a  useful  auxiliary  to  extirpation,  giving  means  for  more 
accurate  diagnosis,  and  giving  time  for  the  patient  to  recruit  her  gen- 
eral health  by  relief  from  the  pressure  before  the  extirpation  is  under- 
taken. Dr.  Fock  published  a  memoir  in  1856,  in  which  it  is  stated 
that  out  of  132  cases  of  ovarian  disease  tapped  for  the  first  time, 
twenty-five  died  within  some  hours  or  a  few  days.  Kiwisch  lost  nine 
patients  out  of  sixty-four  within  twenty-four  hours  after  the  first  tap- 


TAPPING    BY     ABDOMEN.  331 

ping.     Mr.  Southam,  of  Manchester,  collected  twenty  cases  of  tapping 
from  various  sources;  of  these  four  died  within  a  few  hours. 

I  think,  however,  these  figures  give  an  exaggerated  idea  of  the  danger 
of  tapping,  if  the  operation  be  performed  with  proper  circumspection. 
Still  it  must  be  admitted  that  tapping  is  attended  by  considerable  risk. 

The  Operation  of  Tap])ing  by  the  Abdomen. 

A  trocar  made  on  Mr.  Wells's  plan,  modified  from  that  of  Mr. 
Charles  Thompson,  of  Westerham,  designed  for  paracentesis  thoracis, 
secures  against  most  of  the  accidents  liable  to  attend  the  use  of  ordi- 
nary trocars.  The  edges  of  the  canula  should  not  be  thin,  but  perfectly 
smooth  and  well  rounded  oif.  This  best  obviates  the  risk  of  injury  to 
large  veins  on  the  inner  surface  of  the  cyst ;  and  the  maker  should  be 
careful,  when  sharpening  the  cutting  part  of  the  hollow  trocar,  to  leave 
one  half  of  the  lips  quite  blunt.  If  sharpened  all  round  it  would 
act  as  a  punch,  and  cut  out  a  ciruclar  hole  in  the  skin.  If  the 
instrument  is  properly  finished,  only  a  semilunar  cut  is  made  in  the 
skin  and  cyst,  which  closes  much  more  readily  than  the  triangular 
puncture  made  by  the  old  trocar.  To  the  trocar,  a  long  elastic  tube  is 
attached,  which  can  be  made  to  act  as  a  syphon,  exerting  suction-power 
fi'om  the  cyst.  In  piercing  the  cyst,  care  is  taken  that  the  point  of  the 
instrument  is  maintained  at  a  lower  level  than  the  commencement  of 
the  tube,  so  in  fact  that  the  canula  makes  the  short  leg  of  the  syphon, 
whilst  the  conducting  tube  makes  the  long  leg.  Thus  the  moment  the 
canula  enters  the  cyst,  the  rush  of  fluid  into  it  drives  the  air  in  the 
canula  and  tube  before  it,  and  running  along  the  tube  or  long  leg  of  the 
syphon,  a  strong  outward  suction-power  is  at  once  at  work.  The  far 
end  of  the  tube  may  be  kept  under  water.  This  is  especially  desirable 
towards  the  end,  when  the  cyst  is  nearly  empty.  In  withdrawing  the 
instrument  it  is  always  well  to  press  the  abdominal  wall  well  down 
upon  the  cyst,  and  with  the  finger  and  thumb  of  the  other  hand  so  to 
press  the  abdominal  wall  together  behind  the  escaping  canula,  as  to 
prevent  the  entrance  of  air. 

Should  any  bleeding  follow,  and  not  be  stopped  by  a  little  pressure, 
a  harelip  pin  should  be  passed  completely  across  the  opening,  deeply 
enough  beneath  the  skin  to  compress  any  injured  vessel.  Two  or  three 
turns  of  silk  twisted  round  the  pin  make  sufficient  pressure  to  stop  any 
bleeding. 

In  ordinary  cases  a  small  pad  of  lint  and  a  slip  of  adhesive  plaster 
suffice  to  close  the  opening.  It  is  often  useful  to  apply  pads  or  com- 
presses of  lint  or  napkins  in  the  flanks  to  fill  up  the  spaces  left  flaccid 
and  hollow  by  the  withdrawal  of  the  fluid.  The  abdomen  may  then 
be  supported  by  a  binder  over  all. 

The  best  position  is  the  semi-recumbent  in  bed.  Empty  the  bladder 
by  catheter.  It  is  important  to  puncture  low  down.  A  firm  thick 
linen  binder,  having  a  long  slit  in  the  middle,  is  applied  round  the 
abdomen  so  that  the  slit  corresponds  with  the  linea  alba  below  the 
umbilicus ;  the  two  ends  are  then  crossed  behind  the  back  and  brought 
out  in  front,  one  on  each  side.     The  incision  and  puncture  are  made  as 


332  OVAEIAN    TUMORS. 

already  described  in  a  selected  part  through  the  slit,  and  compression  is 
kept  up  as  the  fluid  escapes  by  assistants  pulling  upon  the  ends  of  the 
binder.  If  the  canula  gets  choked,  it  may  be  cleared  by  hooking  out 
the  obstructing  matter  with  a  wire.  If  the  flow  stops  while  the  tumor 
is  only  partly  collasped,  this  may  be  due  to  the  existence  of  other  cysts 
which  do  not  communicate  with  the  one  tapped.  It  may  then  be  de- 
sirable to  pass  a  sound  through  the  canula  to  feel  for  these  other  cysts, 
which  may  be  punctured  and  drained  like  the  first.  Or  there  may  be 
a  solid  residuum  which  precludes  all  further  benefit  from  tapping. 
Sense  of  fainting  or  actual  syncope  often  attends  the  evacuation,  so  that 
stimulants  should  be  at  hand. 

One  effect  following  upon  tapping  is  a  temporary  revival  of  the  secre- 
ting power  of  the  kidneys.  The  quantity  of  urine  thrown  off  is  often 
considerably  increased  for  a  time. 

Tapping  Gomhined  with  injection  into  the  Cyst  of  iodic  or  other 
irritating  fluids. 

The  success  attending  the  injection  of  wine  or  iodic  solutions  into  the 
sac  of  hydrocele  of  the  testicle  naturally  led  to  the  imitation  of  this 
practice  in  the  treatment  of  ovarian  cysts.  But  the  analogy  between 
the  cases  is  only  apparent.  A  simple  serous  sac  which  can  be  perfectly 
surveyed  and  commanded  is  in  reality  widely  different  from  the  imper- 
fectly accessible  and  probably  proliferous  ovarian  cyst.  The  difference 
in  size  alone  alters  the  conditions  materially.  Still  the  method  of  in- 
jecting has  been  taken  up  with  enthusiasm,  especially  by  Boinet,  who 
in  a  valuable  work'  details  several  cases  in  which  it  was  successfully 
employed.  He  urged  that,  when  the  cyst  was  unilocular,  filled  with  a 
limpid,  lemon  liquid  flowing  easily,  and  the  patient  otherwise  of  good 
constitution,  it  should  be  tapped  and  an  iodic  injection  made  immedi- 
ately afterwards.  When  the  contents  were  drawn  off  he  passed  an 
elastic  catheter,  of  size  just  fitting  the  canula,  through  the  canula,  which 
was  then  withdrawn,  leaving  the  catheter  in  its  place.  Through  this 
the  injection  was  made.  He  used  equal  parts  of  tincture  of  iodine  and 
water,  adding  a  little  iodide  of  potassium.  Of  this  solution  he  threw 
in  about  three  ounces.  The  cyst  was  then  kneaded,  and  the  position 
of  the  patient  changed  so  as  to  insure  free  contact  everywhere  of  the 
solution ;  it  was  then,  after  five  or  six  minutes,  withdrawn,  if  necessary, 
by  aid  of  the  syringe.  The  catheter  was  then  removed,  and  the  abdo- 
men well  compressed  and  supported  by  a  bandage.  If  fluid  collected 
again  in  the  cyst  he  would  repeat  the  injection  several  times,  anticipa- 
ting refilling  and  distension. 

In  multilocular  cysts  containing  a  thick  liquid,  flowing  with  diffi- 
culty, further  care  is  necessary.  A  large  trocar  was  employed,  and 
after  letting  all  the  fluid  that  could,  run,  a  catheter  was  passed,  and  a 
syringe  applied  to  draw  out  all  the  thick  viscid  matter  remaining.  The 
rest  of  the  proceeding  was  the  same  as  in  the  simple  cysts.  But  in 
complicated  cysts  it  was  sometimes  necessary  to  keep  the  catheter  in. 

'  "lodoth^rapie  "     Paris,  1855. 


KEEPING    OPEN    THE    CYST.  333 

This  was  to  be  done  when  the  cyst  showed  no  tendency  to  obliteration. 
In  these  cases  the  catheter  was  plugged,  fixed  by  a  bandage,  and  unstop- 
ped two  or  three  times  a  day  to  let  oiF  the  gathering  fluid.  Washing 
out  the  cyst  with  tepid  water  or  weak  solution  of  iodine  was  practiced 
occasionally  to  prevent  decomposition,  and  to  clean  out  the  cyst. 
When  the  fistulous  opening  formed  by  the  catheter  was  well  established, 
so  that  all  escape  into  the  peritoneal  cavity  was  prevented  by  adhesions, 
the  catheter  was  replaced  by  an  ivory  canula  furnished  witli  a  stop- 
cock. Then  iodic  injections  and  washings  were  performed  from  time 
to  time.  The  result  was  slow,  the  cysts  taking  months  to  contract  and 
shrivel  up. 

Since  the  publication  of  Boinet's  work  I  have  practiced  iodic  injec- 
tions a  good  many  times.  In  three,  perhaps  four,  cases,  the  cure  was 
complete  and  permanent.  These  were  apparently  monocystic  tumors. 
Possibly  they  might  have  been  simple  cysts  of  the  broad  ligament ; 
and  possibly,  also,  simple  puncture  without  iodic  injection  might  have 
cured  them.  In  other  cases,  undoubtedly  polycystic,  I  could  not  satisfy 
myself  that  good  was  effected.  Suppurative  inflammation  of  the  cysts 
set  in,  and  a  fatal  result,  not  visibly  accelerated  by  the  treatment,  fol- 
lowed. In  other  cases  the  sac  refilled,  the  patients  left  the  hospital,  or 
were  submitted  to  ovariotomy.  Acute  pain  and  a  degree  of  collapse 
not  seldom  set  in  during  or  soon  after  the  injection. 

In  all  the  cases  it  was  easy  to  detect  iodine  in  the  urine ;  in  one  case 
a  strong  iodic  odor  was  given  off  from  the  patient.  I  detected  iodine 
in  the  perspiration  and  in  the  breath.  In  another  case,  as  well  as  in 
the  foregoing,  the  signs  of  iodism  were  marked.  But  I  have  not  seen 
a  case  in  which  it  could  be  said  that  the  patient  was  fatally  poisoned 
by  the  iodine. 

Scanzoni  and  others  think  iodic  injections  ought  to  be  rejected  alto- 
gether. 

Since  simple  tapping  may  prove  fatal,  it  can  hardly  be  expected  that 
tapping,  plus  iodic  injection,  should  be  free  from  danger.  Dr.  R.  L5w- 
enhardt^  relates  a  case  in  which  oiv  of  a  mixture  of  equal  parts  of 
tincture  of  iodine  and  water,  with  gr.  x  of  iodide  of  potassium,  was 
injected.  Death  followed  in  fourteen  hours.  The  cyst  was  found  col- 
lapsed ;  there  was  no  trace  of  inflammation ;  in  the  cyst  was  a  small 
quantity  of  clear-brown  weakly  iodized  fluid.  Death  was  ascribed  to 
shock, 

Legrand^  relates  the  case  of  a  woman  aged  fifty-six,  in  whom  a 
puncture,  followed  by  iodine  injection,  was  made.  Little  reaction  en- 
sued ;  in  eight  days  the  patient  was  up ;  the  dropsy  quickly  returned. 
The  operation  was  repeated,  and  twelve  to  fourteen  pints  of  fluid  were 
let  out.  At  the  instant  of  injection  the  patient  sank  into  syncope ;  a 
strong  shivering,  vomiting,  peritonitis  set  in,  and  death  followed  in 
sixteen  hours.  In  this  case,  probably,  some  of  the  injection  escaped 
into  the  peritoneum. 

It  is  better,  I  think,  to  use  the  concentrated  tincture  of  iodine. 
There  must  always  remain  fluid  enough  in  the  cyst  to  dilute  it,  and  if 

'  "Monatsschr.  f.  Geburtsk,"  1860.  2  "  Gazette  des  Hopitaux,"  1861. 


334  ovARiAisr  tumors. 

used  already  much  diluted,  its  caustic  action  on  the  cyst-wall  is  lost, 
whilst  absorption  into  the  system  is  promoted. 

In  performing  the  operation,  the  patient  should  be  on  her  side  in 
bed.  Tapping  must  be  performed  in  the  usual  Avay ;  and  when  the 
cyst  is  nearly  emptied,  a  flexible  catheter,  closely  fitting  the  canula, 
should  be  passed  quite  through  it,  so  that  the  end  shall  project  two  or 
three  inches  beyond  the  canula  into  the  cyst.  Then  the  remaining 
fluid  should  be  allowed  to  drain  from  the  cyst.  When  no  more  can 
be  obtained,  four  ounces  of  tincture  of  iodine  should  be  injected 
through  the  canula,  and  allowed  to  remain  about  ten  minutes.  It  may 
then  be  dramed  ofl"  as  far  as  possible.  I  would  then  advise  that  an 
ounce  or  two  of  water  be  injected  through  the  catheter  to  clear  it  of 
iodine  before  removal.  The  catheter  and  canula  may  then  be  with- 
drawn together,  taking  care  to  keep  the  thumb  over  the  end  of  the 
catheter,  to  prevent  the  escape  of  iodic  fluid  into  the  peritoneum  during 
the  passage  of  the  instrument  through  the  wound.  I  have  described 
Boinet's  method  with  care,  because,  although  it  is  very  far  from  having 
realized  the  expectations  at  one  time  formed  of  it,  I  still  think  it  would 
be  unwise  to  reject  it  altogether.  It  may  fairly  claim  to  be  adopted  in 
certain  cases  where  circumstances  exclude  ovariotomy,  such  as  refusal 
of  patients  to  submit  to  this  operation,  or  the  complication  of  severe 
disease,  as  phthisis. 

Tapping  and  keeping  open  the  Cyst — By  this  plan  it  was  hoped  that 
the  fluid,  being  allowed  to  escape  as  quickly  as  it  formed,  tlie  cyst 
would  go  on  contracting  gradually  to  complete  obliteration.  It  was 
also  expected  that  the  irritation  set  up  in  the  cyst-walls  would  promote 
the  attainment  of  this  result.  A  favorable  case  is  reported  by  Ollen- 
roth  (1843).  Mr.  Alexander  Anderson,  my  colleague,  when  obstetric 
physician  to  the  Western  General  Dispensary,  treated  two  cases  in  this 
way,  leaving  a  canula  in  the  cyst.  One  woman  recovered  completely 
after  long  suffering,  suppuration  having  gone  on  through  the  canula, 
attended  with  hectic  and  great  emaciation.  I  saw  this  case  several 
times,  and  could  not  help  forming  the  opinion  that  her  power  of  re- 
sistance against  exhausting  influences  Avas  exceptional.  The  other 
woman  died  a  few  weeks  after  the  tapping,  from  constant  vomiting. 
Mr.  Anderson  abandoned  the  practice.  It  is  not,  I  apprehend,  likely 
to  be  revived,  unless  in  very  exceptional  cases. 

Cases  have,  however,  occurred  in  which,  after  simple  tapping,  the 
punctured  wound  has  kept  open  spontaneously,  giving  vent  from  time 
to  time  to  cystic  fluid.     In  this  way  a  slow  cure  has  been  effected. 

Incision  of  the  Cyst. — Ledran  advised  and  practiced  the  following 
operation.^  When  the  liquid  is  thick,  and  contained  in  several  cysts, 
he  made  an  incision  in  the  most  dependent  part  of  the  tumor,  and, 
according  to  its  position,  either  in  the  median  line,  or  outside  the  recti 
muscles ;  he  then  divided  the  cyst  in  the  same  direction,  and  broke 
down  the  internal  septa,  which  could  be  reached.  He  placed  in  the 
wound  a  strip  of  soft  rag,  for  which,  at  a  later  period,  he  substituted  a 
tent,  and  at  last  a  canula,  to  preserve  free  vent  for  discharges  and  for 

'  See  Malgaigne,  "  M<5decine  Op^ratoirc,"  4eme  ed.,  1843. 


OVARIOTOMY.  335 

detersive  injections.  By  this  proceeding  the  cysts  empty  themselves, 
their  walls  suppurate,  cleanse,  and  contract.  Sometimes  a  fistula,  diffi- 
cult to  close,  remained.  It  was  found  that  owing  to  the  retraction  of 
the  cyst,  the  opening  in  it  getting  below  the  level  of  that  in  the  abdom- 
inal wall,  fluid  would  escape  into  the  peritoneum.  To  obviate  this 
accident,  E.6camier  and  others  sought  to  effect  adhesion  between  cyst 
and  abdominal  wall  before  incision  by  caustics  ;  Trousseau  by  repeated 
insertion  of  several  long  needles ;  Begin  by  cutting  through  the  ab- 
dominal wall,  so  as  to  bare  the  cyst,  and  waiting  until  adhesion  had 
formed  all  round  the  wound  before  tapping  and  incision  of  the  cyst. 

The  results  of  the  operation  have  not  established  for  it  a  claim  to  a 
recognized  place  in  the  rank  of  elective  proceedings.  It  is  now  chiefly 
known  as  a  pis  aller,  as  the  best  thing  to  do  in  certain  cases  where  the 
attempt  to  perform  ovariotomy  breaks  down,  either  from  insurmount- 
able adhesion  or  other  complications.  In  this  way  some  most  unex- 
pected recoveries  have  taken  place.  It  scarcely  differs  in  principle 
from  the  preceding  operation,  of  keeping  open  a  fistulous  canal  after 
tapping.  The  dangers  attending  it  are  greater,  and  therefore  it  falls, 
d  fortiori,  under  the  like  condemnation. 

A  modification  of  this  proceeding  was  proposed  by  Deneux  and 
Sacchi.  It  consists  in  cutting  away  portions  of  the  wall  of  the  cyst. 
Malgaigne  advises  it  as  a  resource  when  extirpation  cannot  be  carried 
out. 

In  a  case  recently  operated  upon  by  Dr.  Chambers,  at  the  Chelsea 
Hospital  for  Women,  Dr.  Aveling  and  myself  assisting,  adhesions  ren- 
dered it  unwise  to  proceed  with  the  intended  extirpation.  The  cyst 
was  compound ;  all  the  contents  that  could  be  easily  removed  were 
taken  away ;  and  the  cyst-wall  being  included  in  the  sutures  through 
the  abdominal  wall,  the  wound  was  closed,  all  but  a  small  part  at  the 
lower  end.  Several  weeks  later  the  wound  only  gave  vent  to  a  slight 
oozing  of  pus,  and  the  patient  was  in  a  fair  way  to  recovery. 

The  excision  of  a  part  of  the  exposed  cyst,  and  then  closing  the  ab- 
dominal wound,  was  proposed  by  Mr.  Baker  Brown.  It  is  a  deliberate 
imitation  of  those  cases  of  accidental  rupture  of  the  cyst  in  M^hich  the 
fluid  effiised  into  the  peritoneum  has  been  absorbed  and  excreted.  The 
abdominal  cavity  was  opened  by  a  small  incision,  a  part  of  the  cyst  was 
laid  bare,  then  punctured  by  a  trocar,  and  the  nature  of  the  contents 
ascertained.  If  limpid  serum  was  found,  a  part  of  the  cyst-wall  was 
drawn  through  by  a  sharp  hook,  and  excised.  The  abdominal  wound 
was  then  closed.  The  cyst  would  thus  continue  to  discharge  into  the 
peritoneal  cavity,  whence  it  would  be  removed  by  absorption  and  ex- 
creted. The  operation  has  not,  I  think,  been  often  practiced.  Repeated 
simple  tapping  would  appear  preferable.  It  is  better  to  get  rid  of  the 
fluid  directly,  than  to  let  it  flow  into  the  peritoneum. 

Encouraged  by  the  fact  that  many  cures  have  followed  the  accidental 
bursting  of  an  ovarian  cyst,  and  discharge  of  its  contents  into  the  peri- 
toneal cavity,  whence  they  have  been  removed  by  absorption.  Dr.  Blun- 
dell  and  others  have  been  led  to  hope  that  ovarian  dropsy  might  be 
successfully  treated  by  deliberate  imitation  of  this  accidental  process. 
Gu^rin,  Bainbridge,  and  others  attempted  to  carry  out  this  idea  by 


336  OVAEIAN    TUMORS. 

making  a  subcutaneous  incision  in  the  wall  of  the  sac  by  means  of  a 
small  tenotomy-knife.  But  this  mode  of  proceeding  is  open  to  the 
grave  objection  that  it  is  working  in  the  dark.  Many  tumors  have 
large  vessels  ramifying  on  the  surface,  which,  if  divided,  might  give  rise 
to  fatal  hemorrhage.  Mr.  Bainbridge  operated  by  cutting  down  on  the 
tumor,  and  excising  a  piece  of  the  cyst-wall.  But  this  plan,  like  Gu6- 
rin's,  is  open  to  the  objection  that  the  fluid  which  is  to  be  thrown  into 
the  peritoneal  cavity  may  be  of  a  viscid  and  irritating  character.  It  is 
true  that  by  his  plan  Bainbridge  avoids  the  risk  of  wounding  vessels ; 
and  as  it  gives  the  opportunity  of  seeing  the  nature  of  the  tumor  and 
its  contents,  the  operation  need  not  be  proceeded  with.  It  might  be 
treated  thus  far  as  an  exploratory  operation,  the  information  gained 
from  which  would  govern  ulterior  measures. 

The  late  Professor  Simpson  thought  the  proceeding  might  be  use- 
fully modified  by  making  a  preliminary  tapping,  with  the  view  of  as- 
certaining the  nature  of  the  fluid;  and  if  this  were  found  to  be  benign, 
to  allow  it  to  escape  into  the  peritoneum.  In  this  way,  he  says,  hav- 
ing made  sure  that  the  fluid  was  innocuous,  he  stopped  the  tapping  by 
shutting  up  the  cutaneous  orifice,  and  allowed  the  last  part  of  the  fluid 
to  run  into  the  cavity  of  the  abdomen.  To  provide  for  the  escape  of 
subsequent  secretion  into  the  abdomen,  it  is  necessary  to  keep  the  lips 
of  the  puncture  in  the  cyst  from  closing  by  first  intention.  This  is  the 
great  difficulty.  To  gain  this  object,  he  sometimes  made  use  of  a  large 
quadrangular  trocar.  He  then  forcibly  compressed  the  tumor  daily, 
so  as  to  break  down  the  adhesions  which  tended  to  close  the  cyst.  In 
this  way,  at  least,  one  cure  was  effected. 

Ovariotomy,  or  Extirpation  of  the  Diseased  Ovary. 

This  operation  has  slowly  made  its  way  against  prejudice,  and  the 
many  failures  necessarily  attending  the  tentative  operations  performed 
whilst  the  conditions  of  success  were  unknown.  It  may  at  last  be  said 
to  be  admitted  to  a  recognized  place  amongst  the  legitimate  resources  of 
surgery.  Acting  on  this  assumption,  I  may  conveniently  omit  much 
historical  and  argumentative  matter.  Ample  details  will  be  found  in 
the  works  of  Wells  and  Peaslee.  The  operation  was  suggested  by 
William  Hunter;  its  practicability,  and  the  mode  of  performing  it, 
were  taught  by  John  Bell ;  it  was  first  practiced,  and  that  successfully, 
by  an  American,  Dr.  McDowell,  a  pupil  of  John  Bell.  But  it  is  mainly 
to  the  enterprise  and  skill  of  British  surgeons  that  it  has  attained  its 
present  position.  Up  to  this  day,  the  operations  in  Great  Britain 
alone  form  a  very  large  proportion,  if  not  an  actual  majority,  of  the 
total. 

Ovariotomy  has  been  contrasted  with  tapping.  The  fallacy  that 
deprives  this  comparison  of  all  practical  application  is  of  the  same  kind 
as  that  which  invalidates  all  absolute  doctrines  in  medicine.  There  are 
cases  for  which  ovariotomy  is  best ;  there  are  cases  f(5r  which  tapping 
is  best.  The  great  distinction  between  the  two  operations  is,  that  the 
first  kills  or  cures;  whilst  the  second  hardly  ever  cures,  and  can,  at  best, 
prolong  life.     Looking  to  cure,  we  should  prefer  ovariotomy,  if  the 


OVARIOTOMY.  337 

case  admitted  of  this  operation ;  looking  to  mere  palliation,  we  must 
in  many  cases  resort  to  tapping.  The  first  is  more  an  operation  of 
choice,  the  second  rather  one  of  necessity. 

It  has  been  urged  against  tapping  that  it  lessens  the  chance  of  ovari- 
otomy being  successful  by  promoting  the  formation  of  adhesions.  This 
objection  has  been  disposed  of  by  experience.  The  moderate  parietal 
adhesions  following  tapping  rarely  present  any  serious  obstacle  to  the 
execution  of  ovariotomy.  On  the  other  hand,  tapping  is  often  useful 
in  clearing  up  the  diagnosis ;  as  a  means  of  gaining  time  for  the  pa- 
tient's general  health  to  recover ;  or  of  lessening  the  shock  by  remov- 
ing the  flnid  a  few  hours  or  days  before  removing  the  solid  portion  of 
an  ovarian  cyst.  Thus,  it  may  be  affirmed,  that  tapping  promotes  the 
success  of  ovariotomy,  instead  of  being  antagonistic  to  it, 

PreGcmtions  before  Operating. 

1.  It  is  needless  to  say  that  a  good  diagnosis  is  the  first  point. 

2.  If  there  is  much  anasarca  or  oedema  of  the  legs,  it  is  well  to  tap 
some  days  previously.  The  eftiised  fluid  becomes  absorbed  and  ex- 
creted, thus  removing  what  might  be  an  injurious  complication.  If 
this  be  not  done,  the  absorption  process  must  go  on  simultaneously 
with  the  wished-for  process  of  healing  from  the  operation.  In  this  case 
the  quality  of  the  blood  is  impaired  by  having  thrown  into  it,  just  at 
the  wrong  time,  a  large  quantity  of  watery  and  effete  material. 

3.  Examine  the  urine  for  albumen.  The  presence  of  albumen  is 
not  indeed  an  absolute  contra-inclication,  for  it  may  dej^end  upon  tem- 
porary congestion  of  the  kidneys,  the  immediate  consequence  of  pres- 
sure by  the  tumor.  The  tumor  removed,  the  kidneys  may  recover. 
But  if  the  albumen  be  accompanied  by  casts,  by  persistent  oedema  of 
the  legs,  hands,  and  face,  and  be  thus  traced  to  permanent  Bright's 
disease,  the  operation  will  be  likely  to  fail.  Brodie  used  to  insist 
upon  this  condition  as  being  highly  adverse  to  the  success  of  capital 
operations. 

Mr.  Wells  insists  further  that  a  small  quantity  of  highly  concen- 
trated urine,  depositing  mixed  urates  in  abundance,  indicates  a  state  of 
hepatic  and  renal  disorder  which  should  be  corrected  before  operating. 
For  this  purpose  saline  purgatives,  as  sulphate  of  soda,  carbonate  of 
magnesia,  and  lithia  water  may  be  given  with  advantage. 

4.  The  state  of  the  heart  and  lungs  should  also  be  examined  as  to 
their  soundness  and  fitness  for  work.  If  there  is  advanced  phthisis  it 
may  be  of  doubtful  advantage  to  operate. 

5.  The  Season. — Where  there  is  a  choice  it  is  wise  to  follow  Brodie's 
advice  as  to  avoiding  operating  during  an  east  wind.  The  wind  is  of 
more  importance  than  the  mere  season  of  the  year,  the  only  point 
usually  noted  in  statistical  tables.  An  east  wind  in  June  may  bring 
more  hazard  to  a  severe  023eration  than  a  west  wind  in  March. 

6.  If  there  be  evidence  of  malignant  disease  in  the  abdomen  or  else- 
where it  will  rarely  be  advisable  to  operate. 

7.  Ovariotomy  should  not  be  practiced  whilst  the  tumor  is  small, 
nor  until  the  constitution  has  undergone  some  degree  of  impairment 

22 


338     •  OVARIAN    TUMORS. 

from  pressure,  and  the  other  effects  of  the  disease.  It  was  at  one  time 
very  naturally  thought  that  a  patient  would  have  a  better  chance  if  the 
operation  were  performed  whilst  she  was  in  robust  health,  and  the  tu- 
mor was  small.  But  experience  has  not  borne  out  this  a  'priori  reason- 
ing. Wells  prefers  waiting.  Keith  says,  "I  prefer  operating  when 
the  tumor  is  large,  and  when  the  patient  has  suffered  a  good  deal." 

The  place  chosen  for  the  operation  is  a  matter  of  vast  importance. 
It  should  be  fairly  spacious,  light,  well-ventilated,  and  the  furniture 
should  be  limited  to  what  is  necessary.  Carpets  covering  the  entire 
floor  are  objectionable.  A  strip  on  either  side  of  the  bed,  and  a  piece 
or  two  in  places  much  used,  to  prevent  noise,  and  Avhich  can  be  taken 
out  of  the  house  to  clean,  is  an  infinitely  preferable  arrangement. 

The  nurse  should  be  specially  qualified  by  training ;  be  able  to  pass 
the  catheter;  keep  utensils  perfectly  clean  by  disinfectants;  and  able  to 
exercise  efficient  yet  gentle  control  over  the  room.  She  should  have 
nothing  else  to  do.  This  is  a  matter  of  course  in  a  private  house;  but 
it  is  still  more  imperative  in  an  hospital.  A  nurse  attending  an  ovariot- 
omy patient  should  not  come  into  contact  with  any  other  patient ;  above 
all,  she  should  not  be  exposed  to  the  risk  of  contact  with  infectious  or 
surgical  patients.  This  touches  closely  upon  the  great  question  whether 
this  operation  should  be  performed  by  surgeons  in  ordinary  hospitals. 
As  a  general  fact  it  may  be  urged  that  all  serious  surgical  operations 
are  exposed  to  an  increased  element  of  danger  in  large  hospitals ;  but 
that  this  is  not  held  to  be  an  adequate  reason  for  not  performing  them 
there.  The  circumstances  of  the  patient  may  leave  her  little  choice; 
whilst  the  practiced  skill  of  the  hospital  surgeons,  and  the  excellence  of 
the  general  arrangements  of  the  hospital,  may  be  thought  to  outweigh 
the  attendant  disadvantages.  This  much  being  admitted,  it  will  be 
asked,  Is  there  any  special  condition  attached  to  ovariotomy,  which 
makes  this  operation  an  exception  to  the  general  rule,  which  turns  the 
scale  the  other  way?  I  think  there  is.  Ovariotomy  in  some  respects 
has  analogies  with  parturition.  The  sudden  removal  of  an  enormous 
growth  feeding  upon  the  system  leads  to  a  constitutional  revulsion,  and 
suddenly  altered  dynamic  and  constituent  conditions  of  the  circulation, 
which,  as  in  a  woman  after  labor,  render  her  peculiarly  susceptible  to 
external  impressions,  and,  especially,  to  the  deleterious  action  of  mor- 
bific poisons.  To  this  risk  is  added  the  exposure  of  the  peritoneum,  a 
structure  remarkably  obnoxious  to  toxical  influences,  and  easily  absorb- 
ing any  contaminating  matter  which  the  operating  surgeon  or  his  as- 
sistants, who  are  constantly  working,  as  Sidney  Smith  would  say,  in  the 
midst  of  "  pus  and  miasm,"  are  so  likely  to  contract.  This  danger,  I 
believe,  might  be  materially  lessened  by  careful  adaptation  of  the  anti- 
septic methods  which  have  been  so  successfully  applied  in  other  depart- 
ments of  surgery.  It  is  a  little  singular  that  an  operation  requiring 
such  care  beyond  all  others  should  hitherto  be  the  most  neglected  in 
this  respect. 

With  all  possible  precautions,  however,  I  do  not  believe  that  ovariot- 
omy in  large  general  hospitals  will  ever  give  results  that  shall  compare 
favorably  with  ovariotomy  done  in  private  houses  or  small  special  hos- 
pitals.    In  this  country,  at  least,  where  the  rights  of  the  humbler  classes 


OVARIOTOMY.  "      339 

are  respected  to  a  degree  unknown  elsewhere,  it  is  practically  admitted 
that  to  deliver  women  in  lying-in  hospitals  or  in  general  hospitals,  is  a 
proceeding  justifiable  only  under  peculiarly  exceptional  conditions. 
Recognizing  this  unreservedly,  I  have  felt  it  my  duty  steadily  to  resist 
the  extension  of  lying-in  hospitals,  notwithstanding  the  great  tempta- 
tions these  institutions  offer  for  scientific  observation  and  teaching. 
The  passion  for  study  must  be  kept  in  subordination  to  the  claims  of 
humanity. 

Instruments  required. — The  necessary  instruments  for  a  simple  case 
are  few.  A  scalpel,  to  divide  the  abdominal  wall;  a  director,  to  pro- 
tect the  cyst  as  this  division  is  completed ;  a  trocar,  to  empty  the  cyst ; 
a  clamp,  to  secure  the  pedicle;  needles  and  silk,  to  close  the  wound; 
with  forceps  and  ligatures,  to  secure  any  bleeding  vessels,  complete  the 
list.  But  there  is  no  surgical  operation  where  the  surgeon  may  be  so 
met  by  difficulties  where  he  least  expected  them,  so  that  it  is  a  safe  rule 
to  take  to  every  case  a  full  supply  of  instruments  to  meet  every  possible 
emergency.  Clamps  of  different  sizes,  cautery  clamps,  and  cauteries  for 
cases  where  the  clamp  is  not  applicable;  ligatures  and  needles  of  differ- 
ent shapes  and  sizes,  for  cases  where  neither  clamp  nor  cautery  effectu- 
ally deals  with  the  pedicle;  large  hare-lip  pins,  or  acupressure  needles, 
for  cases  where  simple  ligature  cannot  be  trusted;  clamps  with  screw 
fastenings,  for  temporarily  securing  separated  omentum  or  torn  vascular 
adhesions;  artery  forceps  of  different  lengths,  torsion  forceps,  bull-dogs, 
vulsella  specially  adapted  for  holding  large  cysts;  a  chain  and  wire 
§craseur;  drainage-tubes  of  glass,  vulcanite,  or  india-rubber;  and  per- 
chloride  of  iron  should  always  accompany  the  operator. 

The  Operation. 

I  shall  describe  the  operation  very  nearly  as  it  is  performed  by  Mr. 
Spencer  Wells,  whose  experience  and  success  may  fairly  be  said  to  be 
unequalled. 

Prejjaration. — A  strong  narrow  table  is  placed  conveniently  for 
light  and  access.  It  is  covered  with  a  firm  squab,  over  which  is  laid  a 
blanket,  and  then  over  all  a  waterproof  sheet.  Two  or  three  pails  are 
ready  to  receive  the  fluid  and  the  tumor.  A  small  table  is  placed 
within  reach  of  the  operator's  right  hand,  so  that  he  can  help  himself 
to  the  instruments  laid  out  on  it.  Iron  or  copper  cauterizing  imple- 
ments are  kept  in  the  fire.  On  the  fire  also  is  a  kettle  of  water  boiling. 
A  nurse  has  cSarge  of  basins,  cold  water,  several  sponges,  and  pieces  of 
thin  flannel  steeping  in  hot  water,  ready  to  wring  out  when  wanted. 

The  room  is  kept  well  ventilated  by  a  fire ;  but  it  is  not  found  neces- 
sary to  keep  up  a  heat  of  90°  Fahrenheit,  as  it  was  at  one  time  thought 
to  be. 

The  patient  is  clothed  in  flannel  drawers,  stockings,  and  night-gown, 
it  being  important  to  prevent  long  exposure  of  a  large  surface  of  the 
body  to  cold.  She  is  rendered  insensible  by  chloroform,  bichloride  of 
methylene,  or  ether,  in  her  bed,  and  then  removed  to  the  operating- 
table.  Mr.  Keith  prefers  sulphuric  ether,  as  less  liable  to  cause  vomit- 
ing.    The  legs  are  strapped  to  the  table  by  a  belt  like  a  horse-girth. 


340       ■  OVAEIAX    TUMOfiS. 

The  hands  should  also  be  secured  by  straps.  This  avoids  the  necessity 
of  supernumerary  assistants.  It  may  be  laid  down  as  an  axiom,  that 
every  additional  assistant  brought  into  contact  with  the  patient  is  an 
additional  element  of  danger.  A  waterproof,  having  a  slit  in  the  mid- 
dle large  enough  to  permit  of  the  operation  being  done  within  it,  is  laid 
over  the  patient.  The  adjustment  of  this  obviates  all  overflow  and 
mess  on  the  patient  and  the  floor.  An  assistant  stands  at  the  operator's 
left  hand ;  another  opposite  on  the  other  side  of  the  patient.  The  as- 
sistant in  charge  of  the  anaesthetic  apparatus  stands,  of  course,  at  the 
patient's  head. 

In  making  the  incision,  the  following  structures  are  successively 
divided:  1.  The  skin;  2,  the  subcutaneous  areolar  tissue,  with  fat  of 
varying  thickness ;  3,  the  interlaced  fibres  of  the  aponeuroses  of  the 
abdominal  muscles  constituting  the  linea  alba ;  4,  layers  of  the  fascia 
transversalis,  with  more  or  less  fat  (the  uppermost  layer  adheres  closely 
to  the  linea  alba :  the  deepest  layer  is  only  very  loosely  connected  with 
the  peritoneum) ;  5,  the  peritoneum. 

The  peritoneum  may  be  raised  with  a  hook  or  forceps.  The  double 
sharp  hook  of  Mr.  Adams  answers  well.  The  membrane  is  then  di- 
vided by  horizontal  touches  with  the  knife,  and  an  opening  made  large 
enoagh  to  admit  the  insertion  of  a  broad  director.  Upon  this  the  peri- 
toneum should  be  slit  up. 

It  is  desirable  to  keep  the  incision  as  short  as  possible.  If  the  tumor 
will  not  come  through  the  short  incision  first  made,  it  can  afterwards 
be  lengthened. 

The  incision  is  made  with  a  scalpel  in  the  linea  alba  from  below  the 
umbilicus  towards  the  pubes,  three  or  four  inches  long  at  first,  pro- 
ceeding very  carefully  as  the  peritoneum  is  approached,  lest  the  cyst  be 
penetrated,  and  its  contents  escape  into  the  peritoneum  before  the  wound 
is  completed.  The  peritoneum  may  be  protruded  through  the  wound 
by  some  ascitic  fluid  behind  it,  and  impose  upon  the  operator  for  the 
cyst.  The  touch  will  commonly  correct  this  by  feeling  the  more  solid 
cyst  behind  it.  The  peritoneum  is  then  opened.  The  cyst  comes  into 
view.  If  ovarian,  especially  if  simple,  it  is  recognized  by  a  glistening, 
pearly,  smooth  aspect.  If  it  be  a  compound  cyst  its  surface  may  be 
uneven,  it  may  be  redder,  vascular,  and  even  hard.  If  it  be  a  fibroid 
or  fibro-cystic  tumor  of  the  uterus  tlie  appearance  is  dark-red,  fleshy, 
and  firm.  The  incision  is  made  just  large  enough  at  first  to  admit  the 
hand,  which  should  be  passed  in  dean,  and  carried  round  between  the 
abdominal  wall  and  the  cyst  to  feel  for  adhesions,  and  if  there  be  any 
to  separate  them.  This  is  best  done  all  over  the  front  of  the  tumor, 
whilst  the  cyst  is  full  and  tense.  The  cyst  is  then  punctured  by  a 
smart  stab  with  Wells's  hooked  trocar,  to  wliich  a  large  flexible  tube  is 
attached  to  carry  the  fluid  into  a  receptacle  on  the  floor.  As  the  cyst 
is  collapsing,  its  walls  are  seized  in  one  or  two  places  by  forceps,  so 
made  as  to  hold  a  good  fold  of  the  cyst-wall  without  tearing  it.  N6la- 
ton's  forceps  is  the  best  for  this  purpose.  It  is  constructed  on  the 
principle  of  my  craniotomy  forceps.  The  holding  part  of  each  blade  is 
deeply  furrowed  (not  tootlied),  so  that  the  two  blades  brouglit  into 
apposition  grasp  the  cyst  evenly,  and  hold  by  their  perfect  parallelism 


OVARIOTOMY.  341 

rather  than  by  direct  force.  Such  a  forceps  will  retain  firm  hold  of 
even  delicate  cyst- walls,  whereas  ordinary  hooked  and  toothed  vulsella 
tear  the  cyst.  Mr.  Sydney  Jones  has  also  contrived  a  good  forceps  for 
this  purpose.  Whilst  an  assistant  supports  the  sides  of  the  wound  with 
flannels  wrung  out  of  warm  water,  with  the  double  object  of  preventing 
the  protrusion  of  intestines  and  the  escape  of  fluid  into  the  peritoneal 
cavity,  the  cyst  is  drained  as  far  as  it  will  flow  freely.  At  the  same 
time  gentle  traction  is  made  on  the  cyst,  to  see  if  it  will  turn  out  of  the 
abdomen.  If  this  does  not  occur  readily  the  evacuation  goes  on,  and 
the  hand  is  passed  in  to  explore  all  round  the  tumor,  breaking  down 
adhesions,  if  necessary,  and  ascertaining  the  existence  and  extent  of 
solid  portions,  which  may  by  their  bulk  oppose  the  removal  of  the 
tumor.  If,  during  this  proceeding,  the  cyst-wall  be  kept  well  drawn 
out,  and  over  one  side  of  the  patient,  the  opening  made  by  the  trocar 
will  be  clear  of  the  iibdominal  wound,  and  no  fluid  will  escape  into  it. 
If  there  are  no  adhesions,  or  only  such  as  are  easily  broken  down,  and 
if  there  is  little  or  no  solid  element  in  the  tumor,  it  will  easily  turn  out. 
As  this  is  done,  the  assistants,  with  warm  moist  flannels,  carefully 
press  up  the  abdominal  wall  behind  the  tumor,  so  as  to  keep  the  cavity 
closed.  Care  is  taken,  especially  at  the  last  stage,  to  prevent  the  tumor 
falling  suddenly,  lest  it  drag  injuriously  upon  the  pedicle.  When  it  is 
fairly  out,  and  well  supported,  the  operator  examines  the  pedicle. 

The  Pedicle. — If  the  pedicle  is  of  sufficient  length  to  permit  of  the 
stump  being  secured  outside  the  abdominal  wound,  this  method  should 
be  preferred.  This,  the  so-called  extra-peritoneal  method  of  dealing 
with  the  pedicle,  stands  in  contrast  with  the  method  of  tying  the  pedicle, 
and  leaving  it  in  the  abdominal  cavity,  closing  the  wound  over  all. 
That  many  successful  results  have  been  obtained  by  the  intra-peri- 
toneal  method  of  dealing  with  the  pedicle  is  true,  but  the  proportion  of 
recoveries  after  the  extra-peritoneal  method  is,  I  believe,  larger.  Mr. 
Hutchinson's  introduction  of  the  clamp  to  facilitate  the  extra-peritoneal 
plan  has  been  very  generally  admitted  to  be  one  of  the  most  substantial 
improvements  acquired  for  ovariotomy.  It  is  now  very  extensively 
used.  Securing  the  stump  outside  the  wound  possesses  the  following- 
signal  advantage :  The  surface,  which  may  bleed  or  yield  noxious 
discharges,  is  always  kept  in  sight,  and  all  discharge  escapes  externally. 
It  has  been  urged  that  the  seclusion  of  the  stump  within  the  abdominal 
cavity  places  it  in  a  like  position  to  a  subcutaneous  wound,  and  that  it 
is  consequently  less  likely  to  undergo  decomposition  than  if  exposed  to 
the  air.  The  stump,  it  is  affirmed,  will  be  surrounded  with  benignant 
plastic  effusions,  and  thus  occasion  no  trouble.  These  propositions  are 
to  a  great  extent  true.  But  experience  proves  that  the  method  does  not 
guard  against  danger  so  surely  as  that  of  keeping  the  stump  outside. 
The  ligature  which  is  necessary  to  secure  the  pedicle  must  be  very 
strong ;  it  must  be  drawn  very  tightly  to  close  the  vessels  in  it ;  some- 
times two  or  three  stout  ligatures  are  necessary.  Tliese  themselves  will 
often  be  a  source  of  irritation.  Then,  after  a  while,  the  tissues  embraced 
in  the  liagatures  shrink  a  little,  the  ligatures  become  looser,  and  under 
returning  reaction  bleeding  takes  place  into  the  abdomen.  Mr.  Spencer 
Wells  has  also  observed  that  on  the  return  of  menstruation,  blood  is 


342  OVARIAN    TUMORS. 

poured  out  from  the  surface  of  the  stump.  It  is,  of  course,  as  likely 
that  the  stump  should  menstruate  in  the  cavity  of  the  abdomen  as  out- 
side. For  these  reasons  it  appears  to  me  clear  that  the  stump  should 
be  kept  outside,  M'here  it  can  be  observed,  if  this  course  be  possible. 
This  depends  upon  the  pedicle  being  long  enough  to  afford  a  good  hold 
for  the  clamp,  and  for  this  to  rest  upon  the  abdominal  wall  without 
serious  strain  or  dragging  upon  the  broad  ligament  and  uterus.  This 
dragging  is  the  source  of  great  pain,  and  may  lead  to  inflammation. 
If  it  is  found  to  occur  after  the  clamp  has  been  applied,  it  may  be 
wise  to  tie  the  stump  below  the  clamp  and  let  it  drop  into  the  cavity, 
either  cutting  the  ligature  close,  or  keeping  the  ends  hanging  out  of  the 
wound. 

If  the  stump  be  found  so  short  in  the  first  instance  that  the  clamp 
can  only  be  got  round  it  with  difficulty,  tying  or  the  cautery  must  be 
resorted  to.  Extreme  care  will  be  necessary  to  secure  all  arrest  of 
bleeding. 

If  the  pedicle  is  too  short  for  a  clamp,  Mr.  Wells  seizes  it  by  a  long 
screw  forceps  fenestrated ;  and  through  the  fenestrse  a  strong  whij)-cord 
is  carried  on  a  needle  through  the  pedicle,  and  then  tied.  One  end  of 
the  ligatures  should  be  brought  out  of  the  wound. 

Where  the  pedicle  is  too  short  even  for  the  ligature  to  give  a  secure 
hold,  it  should  be  grasped  by  a  clamp,  and  the  tumor  severed  from  it 
by  the  actual  cautery. 

A  danger  attending  the  clamp  is  that  the  pedicle  strangulated  in  it, 
may  slough  and  fall  back  into  the  abdomen.  This  happened  in  a  case 
at  the  London  Hospital.  The  patient  was  doing  well  until  the  clamp 
was  removed. 

As  soon  as  the  pedicle  is  secured,  search  for  the  other  ovary,  to  as- 
certain if  it  be  not  also  affected  in  a  manner  to  require  removal.  If  a 
fibroid  tumor  be  found  projecting  from  the  uterus,  it  is  better  to  leave 
it  alone. 

Clean  out  the  Abdominal  Cavity. — Kemove  by  sponges  all  ovarian 
fluid  or  blood  which  may  have  found  its  way  in.  This  is  an  object  of 
paramount  importance,  and  especially  so  if  the  contents  of  the  cyst  be 
viscid  or  puriform.  But  too  great  pains  cannot  be  taken  to  prevent 
fluid  getting  into  the  peritoneum.  If  it  be  found,  from  the  cyst  being 
rotten  or  other  cause,  that  the  fluid  will  run  over,  turn  the  patient  on 
her  side,  so  as  to  give  a  dependent  drainage  away  from  the  abdomi- 
nal cavity. 

Closing  the  Abdominal  Wound. — Every  variety  of  suture  has  been 
employed,  and  possibly  the  choice  has  not  much  effect  upon  the  result 
of  the  o])eration.     Most  o]3erators  use  the  silver-wire. 

The  following  is  Mr.  Wells's  plan :  "  Silk  about  eighteen  inches  in 
length  is  threaded  at  each  end  on  a  strong  straight  needle.  Each 
needle  is  introduced  from  within  outwards,  through  the  peritoneum  and 
the  whole  thickness  of  the  abdominal  wall.  The  sutures  are  placed  at 
intervals  of  about  an  inch.  The  ends  of  the  sutures  are  held  up  by  an 
assistant,  who  draws  up  the  lips  of  the  wound  until  all  the  deep  sutures 
have  been  applied.  Then  the  lips  of  the  wound  are  held  ajxu't  again, 
in  order  that  the  operator  may  convince  himself  that  no  further  bleed- 


OVARIOTOMY.  343 

ing  has  taken  place  into  the  abdominal  cavity,  which,  if  required,  has 
to  be  sponged  again.  This  done,  the  sutures  are  tied,  and  the  ends  of 
the  threads  cut  oif.  If  the  abdominal  wall  is  very  thick,  superficial  su- 
tures may  be  required  between  the  deep  ones.  If  the  pedicle  has  been 
secured  by  the  clamp,  a  suture  should  be  passed  close  to  the  latter,  in 
order  to  bring  the  lips  of  the  wound  so  precisely  around  the  pedicle  that 
the  peritoneal  cavity  is  accurately  closed.  The  including  of  the  peri- 
toneum within  the  stitches  is  of  the  utmost  importance.  The  two  peri- 
toneal layers  adhere  very  rapidly.  At  the  post-mortem  examination 
of  patients,  who  died  after  twenty-four  hours,  the  edges  of  the  peritoneal 
incision  have  been  found  firmly  united  by  the  first  intention.  Thus,  pus 
and  other  secretions  are  prevented  from  entering  the  peritoneal  cavity, 
adhesion  of  the  omentum  or  intestine  to  any  part  of  the  inner  aspect  of 
the  wound  not  covered  by  peritoneum  is  prevented,  and  such  firm  union 
is  secured  that  a  ventral  hernia  scarcely  ever  occurs  after  recovery." 

The  clamp  is  then  warded  ofP  from  the  skin  and  wound  by  a  pled- 
get of  lint  dry  or  soaked  in  carbolized  oil  laid  beneath  it.  Mr.  Wells 
uses  pledgets  soaked  in  carbolic  acid  absorbed  in  calcined  oyster-shell. 
The  surface  of  the  stump  is  sprinkled  with  dry  perchloride  of  iron. 

The  Dressing. — Pledgets  of  lint  are  laid  on  the  wound.  Pads  of 
cotton-wool  are  disposed  on  each  side;  broad  strips  of  plaster  are 
passed  over;  and  lastly,  a  flannel  belt  secures  all. 

The  cautery-clamp  is  used  for  the  temporary  compression  of  the 
pedicle.  It  was  devised  by  Mr.  Clay,  of  Birmingham,  in  order  to  stop 
bleeding  from  vessels  in  the  omentum  which  had  been  adherent  to  the 
cyst.  It  is  to  him  we  owe  the  principle  of  combining  compression  and 
cauterization  in  the  suppression  of  hemorrhage.  Mr.  Baker  Brown 
next  applied  this  principle  to  the  pedicle.  Dr.  Skoldberg,  of  Stock- 
holm, and  INIr.  Wells  improved  the  instruments  for  this  purpose.  But 
the  most  efficient  one  I  have  seen  is  that  of  Dr.  Thomas  Chambers. 
The  blades  are  perfectly  parallel,  so  that  equal  pressure  is  applied 
along  the  whole  length  of  the  blades,  compressing  even  a  large  pedicle 
with  great  nicety.  Dr.  Lloyd  Roberts  bears  his  testimony  to  the  effi- 
ciency of  this  instrument  in  practice. 

After-treatment. 

Rest  is  the  great  principle  to  be  observed.  To  help  this  an  opiate 
suppository,  or  an  opium  pill,  should  be  given  two  or  three  times  a 
day,  to  tranquillize  nervous  excitement  and  restrain  action  of  the  bowels. 
If  vomiting  occur,  or  indeed  to  anticipate  it,  give  the  patient  ice  to 
suck;  bismuth  or  oxalate  of  cerium  may  be  combined  with  the  opium. 
The  diet  should  be  highly  nutritious,  not  stimulating:  beef  tea,  milk, 
eggs,  constitute  nearly  all  that  can  be  given  with  safety.  Wine  or 
spirits  must  be  given  very  sparingly,  and  rather  as  means  of  restoring 
the  system  if  it  show  signs  of  flagging,  than  as  a  recognized  part  of  the 
diet.     The  bladder  should  be  emptied  by  catheter  every  eight  hours. 

Unless  local  distress  arise,  the  wound  need  not  be  disturbed  for  three 
days.  On  the  fourth  day  the  stump  may  be  exaniined.  It  will  com- 
monly be  found  shrivelling  up,  sometimes  even  dry.     The  clamp  may 


344  OVARIAN    TUMORS. 

now  be  removed.  If  there  be  any  discharge,  wash  lightly  with  weak 
carbolic  acid,  and  dress  with  lint  steeped  in  carbolic  oil. 

The  abdominal  wound  is  often  firmly  united  in  four  or  five  days ;  but 
the  sutures  may  usefully  remain  until  the  seventh  or  eighth  before 
being  cut  and  removed.  It  is  desirable  to  keep  a  flannel  belt  or  binder 
on  for  some  days  after  this. 

Certain  complications  may  render  it  expedient  to  modify  the  above 
proceedings : 

1.  The  eyst  may  be  so  friable  or  rotten  that  it  breaks  down  under  the 
most  careful  handling.  Great  pains  must  be  taken  to  bring  away  the 
cyst  without  leaving  pieces  of  it  or  the  contents  in  the  abdomen. 

2.  If  the  cyst  is  multiloGular,  so  that  after  tapping  the  main  cyst  the 
tumor  is  still  too  large  to  come  through  without  enlarging  the  abdomi- 
nal incision,  the  septa  should  be  broken  down  by  the  hand,  and  any 
semi-solid  contents  brought  away.  It  is  only  when  accommodation 
cannot  be  got  in  this  way  that  the  incision  should  be  extended. 

3.  Extensive  firm  adhesions  may  be  found  in  front.  These  can  gener- 
ally be  broken  down  by  the  flat  hand  working  under  the  abdominal 
wall.  But  it  may  be  necessary  to  enlarge  the  wound  and  evert  its  lij)S, 
so  as  to  be  able  to  divide  the  adhesions  by  the  handle  of  the  scalpel,  by 
its  edge,  or  by  the  adze-edged  cauterizing  iron.  The  latter  is  perhaps 
the  best  plan,  as  it  stops  bleeding.  The  bands  of  adhesion  are  first 
embraced  by  a  clam,  such  as  the  one  proposed  by  Mr.  John  Clay ;  the 
hot  iron  is  then  applied  to  the  cyst-side  of  the  clam,  which  protects  the 
visceral  side  from  injury.  If  divided  by  knife  it  may  be  necessary  to 
tie  with  silk  or  wire  or  fine  catgut  small  bleeding  vessels.  When  this 
is  done  the  ends  of  the  sutures  should  be  cut  oif  short,  as  they  have  to 
be  kept  in  the  abdomen.  If  obstinate  adhesions  to  the  intestines  are 
found  the  same  means  must  be  employed  to  divide  them.  It  has  been 
found  occasionally  necessary  to  leave  portions  of  the  cyst  adhering.  If 
there  be  adhesions  to  the  omentum  these  must  be  carefully  detached  as 
far  as  possible.  The  omentum  itself  must  then  be  carefully  spread 
out  on  a  clean  napkin,  and  examined  for  bleeding  points.  Wherever 
these  are  found  a  silk  ligature  is  put  round  them,  the  piece  of  omentum 
is  cut  off,  and  the  ligature  cut  short. 

If  adhesions  be  found  insiirmoun table,  the  attempt  to  complete  ex- 
tirpation must  be  abandoned.  We  may  then  fill  back  upon  the  plan 
of  keeping  the  cyst  open  as  in  Ledran's  operation,  trusting  to  the  ob- 
literation of  the  cyst  under  drainage  and  inflammation.  The  after- 
treatment  will  consist  in  occasionally  washing  out  the  cyst  Avith  water 
or  some  detergent  fluid,  as  Condy's  or  weak  carbolic  acid. 

Mr.  Hutchinson  calls  attention  to  a  special  dijficulty  caused  by  ad- 
hesions in  front.  Great  difficulty  may  occur  in  distinguishing  the  cyst. 
The  operator  may  mistake  the  cellular  interspace  between  the  transver- 
salis  fascia  and  the  parietal  peritoneum  for  that  between  the  cyst  and 
the  latter.  If  not  quickly  discovered  this  error  may  be  the  cause  of 
ffreat  damaoje.  In  endeavoring;  to  avoid  it  the  suro;con  mav  commit 
another;  he  may  incise  the  visceral  peritoneum  of  the  cyst,  and  proceed 
to  separate  it.  In  many  cases  the  exterior  of  the  cyst  deprived  of  its 
peritoneum  is  smooth,  white,  and  glistening,  the  adhesions  are  cellular 


OVARIOTOMY.  345 

and  easily  broken  through,  so  that  there  is  nothing  to  apprise  the  oper- 
ator of  his  mistake.  One  plan  there  is  in  case  of  perplexity  to  avoid 
all  risk  of  these  two  errors :  it  is  to  enlarge  the  wound  upwards  until 
the  peritoneal  cavity  is  opened  at  a  part  where  no  adhesions  exist. 
When  once  the  operator's  finger  has  touched  the  intestine  he  knows 
where  he  is,  and  may  proceed  to  detach  adhesions  without  any  fear  of 
mistake. 

In  cases  where  the  detachment  of  the  cyst  would  be  dangerous  or 
impossible.  Dr.  Atlee  has  solved  the  problem  by  a  very  ingenious  plan. 
He  leaves  the  peritoneum  with  its  adhesions,  by  separating  it  from  the 
fibrous  wall  of  the  cyst,  so  that  the  adherent  portion  peeled  off  is  left 
in  contact  with  the  viscus  to  which  it  was  attached.  "  Dr.  W.  L.  Atlee 
has  practiced  this,"  says  Peaslee,  "for  many  years  past.  In  his  215th 
case  adhesions  seven  or  eight  inches  long  were  thus  left  attached  to  the 
transverse  colon." 

When  bad  symptoms  follow  ovariotomy,  as  pain,  vomiting,  fever 
with  abdominal  distension,  there  is  evidence  that  some  fluid,  blood, 
serum,  or  pus  is  collecting  in  the  peritoneal  cavity.  It  may  collect  in 
such  quantity  as  to  give  rise  to  sensible  fluctuation  from  one  side  of 
the  abdomen  to  the  other,  or  it  may  gravitate  to  the  bottom  of  Doug- 
las's space,  and  form  a  tense  swelling  behind  the  uterus.  If  the  pedicle 
has  been  treated  by  ligature  the  ends  of  the  ligature  passing  outwards 
then  serve  as  drainage-conductors,  and  a  very  free  discharge  of  fluid 
may  go  on  for  several  days. 

Whenever  fluid  can  be  detected  by  vaginal  examination  in  the  neigh- 
borhood of  the  uterus,  it  is  usually  in  such  quantity  that  it  must  be 
removed.  This  may  be  done  by  a  long  rather  fine  trocar.  The  seat  of 
puncture  should  be  where  there  is  free  fluctuation  behind  the  uterus, 
so  as  to  strike  a  dependent  part  of  Douglas's  pouch.  A  drainage-tube 
may  be  inserted. 

If,  when  the  pedicle  has  been  returned  into  the  abdomen,  signs  of 
internal  hemorrhage  arise,  it  is  proper  to  open  the  wound  to  get  at  the 
stump,  tie  it  afresh,  and  cleanse  out  the  abdomen.  It  seems  reasonable 
to  think,  what  experience  indeed  proves,  that  it  is  less  dangerous  to  do 
this  than  to  leave  the  patient  to  the  hazards  of  hemorrhage  and  perito- 
nitis. 

Untoward  symptoms  must  be  encountered  according  to  their  indica- 
tions. A  survey  of  the  causes  of  death  under  ovariotomy  will  supply 
the  best  guidance.  The  first  and  most  immediate  cause  is  commonly 
shock  and  collapse.  A  considerable  proportion  of  all  the  deaths,  I  am 
convinced,  occur  from  shock.  Recovery  from  this  is  greatly  a  question 
of  individual  power  of  endurance.  We  can  hardly  foretell  what  this 
power  is  in  any  particular  case.  Women  recover  from  the  severest 
operations  attended  by  all  the  complications  considered  the  most  for- 
midable; others  sink  after  the  easiest  and  simplest  operations.  Women 
comparatively  robust  succumb,  whilst  the  apparently  fragile  recover. 
In  many  cases  the  unexpected  result  is  not  due,  at  least  appreciably,  to 
difference  in  skill.  It  can  only  be  referred  to  difference  in  innate  power 
of  resistance.  This  is  an  unknoAvn  quantity,  and  is  the  chief  cause  of 
the  uncertainty  which  surrounds  the  operation.     No  doubt  the  shock 


346       _  OVARIAN    TUiMORS. 

can  be  lessened  by  care  and  skill  during  operation,  and  the  patient 
can  be  to  some  extent  supported  through  it.  Shock  bears  some  rela- 
tion to  the  length  of  the  operation.  Koeberle  found  the  mortality  in- 
creased with  the  time  spent  in  the  operation.  The  patient  should  be 
carefully  watched  and  supported  during  the  stage  of  depression  which 
follows  the  operation.  A  free  supply  of  wholesome,  fresh,  warm  air, 
without  draughts,  should  be  secured.  If  the  surface  is  cold,  warm- 
water  bottles  must  be  applied  to  the  feet  and  legs;  light  stimulants, 
as  a  little  brandy  and  water,  or  ether,  or  sal  volatile,  may  be  ad- 
ministered. 

Hemorrhage. — Internal  hemorrhage  may  proceed  from  two  sources — 
the  vessels  torn  across  in  separating  adhesions,  and  the  stump.  The 
modes  of  avoiding  or  diminishing  this  risk  have  been  described.  If 
hemorrhage  to  an  extent  to  produce  serious  symptoms  occur,  it  is  better, 
desperate  as  the  expedient  may  seem,  to  open  the  wound,  search  for 
the  source,  and  stop  it  by  styptics,  cautery,  or  ligatures. 

Peritonitis  is  a  frequent  cause  of  death.  It  may  be  purely  trau- 
matic, the  result  of  the  violence  necessarily  done  during  the  operation. 
It  may  be  due  to  the  injury  inflicted  in  separating  adhesions.  But  it 
has  often  been  remarked  that  those  subjects  in  whom  a  large  extent  of 
peritoneum  has  been  altered  in  character  by  previous  attacks  of  inflam- 
mation, leaving  adhesions  to  the  cyst,  are  not  so  prone  to  peritonitis  as 
are  many  subjects  in  whom  there  were  no  adhesions,  the  peritoneum 
retaining  all  its  natural  liability  to  injurious  impressions.  A  more 
serious  form  of  peritonitis  is  one  that  seems  analogous  to  the  puerperal 
form.  Here  there  is  commonly  septicsemia,  or  inflammation  is  propa- 
gated from  the  seat  of  the  pedicle,  in  which  some  unhealthy  action  is 
going  on.  It  will,  of  course,  be  especially  likely  to  occur  in  the  in- 
complete operations,  where  a  portion  of  cyst  has  been  left  behind.  It 
is  also  seriously  promoted  by  the  escape  of  the  fluid  of  the  cyst  into 
the  abdomen,  and  its  imperfect  removal.  The  fluid  has  been  shown  in 
certain  cases  to  possess  a  peculiarly  noxious,  even  poisonous,  property. 

The  earliest  signs  of  peritonitis  are  pricking  and  shooting  pain  in  the 
abdomen ;  or  according  to  Mr.  Hutchinson,  a  peculiar  pallor  of  the 
cheeks  and  an  anxious  expression  of  countenance,  with  frontal  head- 
ache. The  pulse  becomes  quicker  and  smaller,  the  skin  hot,  the  tongue 
a  little  dry,  and  there  is  almost  always  more  or  less  sickness.  At  a 
later  stage  the  face  may  become  flushed,  the  skin  painfully  hot,  whilst 
at  the  same  time  the  pulse  is  rapid  and  very  small.  Distension  of  the 
abdomen  with  flatus  is  a  common  and  distressing  symptom ;  and  at  a 
later  stage  the  intestines  become  involved,  and  the  abdomen  is  full  and 
tympanitic.  The  peritonitis  may  be  local  or  general.  If  limited  to 
the  parts  adjacent  to  the  pedicle  and  to  the  pelvis,  it  is  protective  rather 
than  otherwise,  since  it  tends  to  exclude  irritating  matters  from  the 
general  cavity.  In  cases,  however,  in  which  the  peritonitis  is  encysted, 
very  profuse  discharge  may  take  place,  and  the  patient  may  sink  ulti- 
mately from  exhaustion.  If  from  the  first  the  whole  peritoneum  be  in- 
vaded, recovery  is  rare.  The  treatment:  Locally,  leeches  in  the  earli- 
est stage  are  useful.  The  abdomen  should  be  covered  with  a  liot  lin- 
seed-meal poultice.     The  relief  thus  given  is  not  less  marked  than  it 


OVARIOTOMY.  347 

often  is  in  puerperal  peritonitis.  But  ice  has  been  used  with  apparent 
advantage.  My  own  opinion  agrees  with  Mr.  Hutchinson's  as  to  the 
vakie  of  mercury  and  opium,  at  least  in  the  initiative  stages.  But 
salines  are  also  serviceable,  the  best  being  the  acetate  of  ammonia. 
Where  the  peritonitis  is  of  a  low  or  erysipelatoid  type,  twenty -drop 
doses  of  solution  of  perchloride  of  iron  should  be  tried. 

Septiccemia  may  occur  although  not  commonly,  without  much  peri- 
tonitis. The  symptoms  then  are  very  similar  to  those  of  septicsemie 
puerperal  fever,  and  should  be  treated  in  a  similar  manner. 

Embolism  and  Th'ombosis. — Some  deaths  have  occurred  from  these 
conditions. 

Obstinate  vomiting  or  hiccough  may  attend  peritonitis.  But  some- 
times they  can  only  be  referred  to  irritation  of  the  ganglionic  system, 
the  irritating  cause  being  pain  starting  from  the  structures  included  in 
the  clamp  or  ligature,  or  other  injury.  The  vomiting  started  by  the 
inhalation  of  chloroform  may  persist.  This  danger  is  regarded  by  Mr. 
Keith  as  so  serious,  that  he  has  abandoned  chloroform  for  ether. 

Wells  says,  after  ovariotomy,  the  most  frequent  cause  of  death  is 
peritonitis,  or  some  form  of  fever  or  blood-poisoning  so  often  associated 
with  peritonitis;  then  collapse  or  exhaustion.  He  has  never  lost  a 
patient  from  hemorrhage.  In  two  cases  tetanus  proved  fatal.  In 
some,  obstructed  intestine,  and  in  others  superfibrination  of  blood  and 
deposits  of  fibrous  coagula  in  the  heart,  were  the  immediate  causes  of 
death. 

Two  or  three  further  questions  in  connection  with  ovariotomy  call 
for  discussion : 

1.  How  to  deal  with  a  case  in  ivhich  the  cyst  has  rujAured,  or  has  given 
rise  to  effusion  of  blood,  to  peritonitis,  or  to  septicaemia. 

This  literally  vital  question  has  already  been  partly  answered  by 
anticipation.  The  argument  may  be  stated  as  follows :  The  case  is, 
that  the  patient  is  in  the  most  imminent  danger  from  the  sliock,  irrita- 
tion, and  loss  of  blood  attending  the  injury.  The  shock  may  be  re- 
garded as  a  blow  struck  at  the  vital  powers.  We  cannot  lessen  the 
shock  given  by  this  blow ;  but  we  may,  in  some  cases  where  there  is 
some  rally,  do  good  by  removing  that  which  is  the  cause  of  protracted 
shock.  This  cause  consists  in  the  irritation  arising  from  the  contents 
of  the  cyst,  or  the  blood  eifused  in  the  peritoneum,  which  irritation  is 
quickly  followed  by  inflammation.  Of  course  the  patient  may  sink 
rapidly  under  the  primary  shock,  and  thus  defeat  all  idea  of  giving 
relief  by  operation. 

But,  in  not  a  few  cases,  the  primary  shock  does  not  kill.  The  patient, 
however,  will  hardly  pull  through  the  secondary  dangers  of  hemor- 
rhage and  peritonitis,  unless  these  be  arrested  in  their  course.  There 
is  the  opportunity  of  trying  to  give  relief  to  obviate  these  dangers.  Here 
then  is  a  case  for  the  decisive  application  of  the  great  law  in  medicine : 
Remove  the  offending  cause.  If  extirpation  of  a  diseased  ovary,  which 
is  slowly  sapping  the  vital  powers,  be  recognized  as  a  justifiable  opera- 
tion, a  fortiori  must  the  operation  be  conceded  as  necessary  when  the 
diseased  ovary  is  the  source  of  instant  danger  to  life.  It  would  be  dif- 
ficult to  answer  a  priori  reasoning  like  this,  except  by  urging  that  how- 


348  OVARIAN    TUMORS. 

soever  plausible  in  theory,  it  would  be  useless  in  practice.  But  even 
this  answer,  which  until  recently  was  still  urged,  is  now  deprived  of 
force  by  the  results  of  experience.  When  the  irritating  cause  has  been 
removed,  the  patient  has  recovered. 

Mr,  Wells  says,'  "In  several  of  my  cases  the  operation  has  been 
performed  after  the  cyst  has  burst,  and  its  contents  has  escaped  into  the 
peritoneum.  The  peritoneum  has  been  found  intensely  red,  thick,  soft, 
or  villous,  and  occasionally  covered  by  loosely  adherent  flakes  of  lymph. 
Yet  the  result  has  been  surprisingly  satisfactory.  Tw^enty-four  times 
has  this  complication  presented  itself  out  of  the  last  300  of  my  opera- 
tions. Five  of  the  patients  have  died,  so  that  the  ordinary  rate  of 
mortality  does  not  seem  to  have  been  much  augmented.  At  any  rate 
the  bursting  of  the  cyst,  or  the  filling  of  the  peritoneum  by  oozing  from 
the  puncture  made  by  tapping  the  cyst,  is  no  bar  to  the  operation,  but 
rather  a  reason  for  doing  it  without  delay." 

In  addition  to  the  cases  in  which  ovariotomy  is  resorted  to  deliber- 
ately as  the  best  means  of  rescuing  the  patient  from  a  more  or  less 
lingering  death,  it  is  justified  under  certain  accidental  circumstances  of 
extreme  urgency.  Some  of  these  are  rupture  or  strangulation  of  a  cyst, 
attended  with  intei'ual  hemorrhage  and  shock.  Thus  Drs.  Wiltshire 
and  Watson  have  published  a  case,  where  a  w^oman  dying  from  bleed- 
ing into  an  ovarian  cyst,  was  saved  by  immediate  operation. 

2.  How  to  deal  with  ovarian  cystic  tumors  complicated  laith  pi^egnancy. 

Ovariotomy  during  jjt^egnancy  has  been  performed  several  times,  the 
operator  not  suspecting  the  pregnancy  before  the  operation.  What 
should  be  done  when  a  pregnant  uterus  is  discovered  during  some  stage 
of  ovariotomy  ?  Wells  says,  "  Let  it  alone,"  that  is,  the  uterus.  Dr. 
Atlee  performed  ovariotomy  in  the  second  month  of  pregnancy.  It 
was  followed  by  such  great  irritability  of  stomach,  in  consequence  of 
the  state  of  pregnancy,  that  the  woman  could  not  be  nourished,  and 
she  died,  thirty  days  after,  of  starvation.  In  a  case  related  by  Mr. 
Burd,  of  Shrewsbury,  in  1847,  of  ovariotomy  performed  by  him  in  the 
third  and  fourth  months  of  pregnancy,  abortion  took  place  two  days 
after  operation,  and  was  followed  by  alarming  symptoms,  lasting  several 
days.  Dr.  Marion  Sims  performed  ovariotomy  in  the  third  month, 
not  detecting  the  pregnancy  until  the  ovarian  tumor  had  been  removed. 
The  patient  recovered  well,  and  was  delivered  of  a  fine  child  at  term. 

Mr.  Wells  says,  "  If  inadvertently  the  uterus  be  penetrated,  if  any 
conclusion  can  be  drawn  from  the  case  in  which  I  made  this  mistake 
and  emptied  the  uterus,  aiid  two  other  cases  in  Avhich  the  some  mistake 
was  made  by  other  surgeons,  who  did  not  empty  the  uterus,  but  closed 
the  puncture  in  its  wall  by  wire  sutures,  both  patients  having  died 
after  aborting,  while  mine  recovered,  it  would  appear  to  be  the  safer 
practice  to  empty  the  uterus." 

Wells  relates  four  cases,  in  one  of  which  ovariotomy  was  performed 
at  the  fourth  month  of  pregnancy,  after  rupture  of  the  cyst  and  peri- 
tonitis; in  the  second,  third,  and  fourth  the  operation  was  a  matter  of 

1   "  Diseases  of  tho  Ovaries,"  1872. 


OVAEIOTOMY.  349 

election  to  avoid  other  clangers.     The  result  was  successful,  in  all  three 
giving  birth  to  living  chiklren  at  term. 

When  pregnancy  supervenes  on  ovarian  dropsy,  there  are  three, 
perhaps  four,  courses  out  of  which  to  select. 

1.  We  may  leave  things  alone,  simply  watching,  prepared  to  act,  if 
urgency  from  rupture  of  the  cyst,  axial  twisting,  or  hemorrhage  or  ex- 
cessive pressure  arise.  In  a  cpnsiderable  proportion  of  cases  pregnancy 
goes  on  to  term,  and  the  labor  is  completed  happily.  Is  it  wise  then 
to  stand  by  and  trust  to  the  chance  of  this  issue  ?  If  we  determine  to 
anticipate  danger,  we  may 

2.  Tap  the  cyst.  This  will,  of  course,  at  once  lessen  the  inconveni- 
ence of  pressure,  and  the  danger  of  bursting. 

3.  Or  we  may  act  upon  the  uterus.  We  may  lessen  the  distension 
and  risk  of  rupture  by  drawing  oif  the  liquor  amnii;  that  is,  by  induc- 
ing labor,  postponing  the  question  of  dealing  with  the  tumor,  until  the 
case  is  reduced  to  its  simplest  expression,  by  eliminating  the  pregnancy. 
I  have  discussed  this  question  in  my  work  on  "Obstetric  Operations," 
and  have  there  given  the  reasons  which  appear  to  me  to  ^veigh  in  favor 
of  this  course.  The  opposite  view,  that  of  acting  on  the  ovarian  tumor 
by  tapping  or  extirpation,  is  well  argued  by  Mr.  Goddard  (Obstr. 
Trans.,  1871).  No  doubt  in  certain  cases,  either  proceeding  may  be 
preferable  to  the  other.  But,  as  a  general  rule,  I  believe  experience 
will  show  that  it  is  better  to  act  first  upon  the  pregnant  uterus. 

Mr.  Wells  refers  to  five  patients  whom  he  has  tapped  during  preg- 
nancy, one  of  them  three  times,  once  twice,  and  three  once.  In  all 
these  women  great  relief  was  afforded  by  the  tapping,  no  ill  effect  of 
any  kind  was  observed  to  follow  it,  and  in  all  the  children  were  born 
alive,  after  labors  of  moderate  duration. 

There  is  a  peculiar  state  of  nervous  and  vascular  tension  produced 
by  pregnancy  which  should  be  taken  into  account.  Pregnancy  induces 
great  irritability  of  the  nervous  centres,  spinal  and  cerebral.  This 
irritability  accounts  for  the  greater  risk  of  abortion,  of  vomiting,  if  in- 
terference be  resorted  to.  It  also  is  a  source  of  danger  if  accident  or 
complication  arise,  as  rupture  of  cyst,  inflammation,  &c.  And  as  this 
complication  may  be  more  serious  than  the  operation,  the  operation 
may  become  justifiable  as  the  lesser  danger. 

Believing,  as  I  do,  that  a  woman  in  whom  pregnancy  is  complicated 
with  an  ovarian  cyst,  is  in  a  position  of  imminent  peril;  that  her  life 
is  threatened  at  any  moment  by  some  catastrophe  which  may  strike  so 
suddenly  and  so  violently  as  to  leave  no  time  for  action,  my  opinion  is 
decidedly  in  favor  of  eliminating  the  pregnancy.  I  have  acted  on  this 
principle  on  several  occasions  with  a  successful  result,  not  counterbal- 
anced by  a  single  unsuccessful  one. 

4.  If  the  cyst  actually  burst,  or  give  rise  to  hemorrhage  or  periton- 
itis, there  should,  I  think,  be  no  hesitation  in  attempting  removal  of 
the  tumor,  which  is  the  cause  of  immediate  danger. 


350  FALLOPIAN    TUBES. 


CHAPTER  XXXIY. 

THE  FALLOPIAN  TUBES:  ABSENCE  OF;  SEPAEATION ;  CYSTS 
CARCINOMA;  TUBERCLE;  FIBROID  TUIVIORS;  HYPERTROPHY 
ELONGATION;  DILATATION;  INFLAMMATION  (SALPINGITIS) 
CATARRH;  H.EMATOMA;  OCCLUSION;  CYSTIC  ENLARGEMENTS 
DROPSY. 

The  pathology  of  the  Fallopian  tubes  deserves  more  attention  than 
it  has  commonly  received.  The  diagnosis  of  the  diseases  to  which  the 
tubes  are  liable  is  not  so  difficult  as  it  may  at  first  sight  appear  to  be. 
The  natural  issue  of  some  of  these  diseases  is  in  sudden  death ;  and 
this  catastrophe  may,  in  many  cases,  be  averted  by  timely  treatment. 

The  tube  of  one  side  may  be  wanting  if  the  corresponding  side  of  the 
uterus  is  wanting.  In  many  cases  the  tube  is  represented  by  an  im- 
pervious string.  In  some  cases  there  is  only  seen  a  small  rounded 
stump  attached  to  the  horn  of  the  uterus.  This  last  condition,  says 
Rokitansky,  is  mostly  the  result  of  a  twisting  and  separation  of  the 
tube.  As  conditions  of  excessive  development,  we  sometimes  see  super- 
numerary fimbrise,  and  accessory  openings  into  the  abdominal  cavity. 
Appended  to  the  fimbriated  extremity  is  often  found  a  small  clear 
pyriform  vesicle  hanging  by  a  peritoneal  stalk,  which  Rokitansky  says 
is  the  remains  of  a  pinched -oif  portion  of  a  Wolffian  duct. 

The  tubes  are  not  very  subject  to  new  formations;  small  tumors, 
fibrous  or  fatty,  sometimes  occur,  but  possess  little  clinical  importance. 

Cysts,  however,  often  occur  in  great  numbers  in  the  broad  ligament, 
and  have  their  seat  especially  on  and  near  the  tubes,  and  on  the  ovaries. 
They  are  generally  small,  and  contain  a  colloid  moisture.  The  smallest 
appear  as  delicate  vesicles  formed  out  of  a  fibrous  capsule.  They  occur 
only  in  mature  and  advanced  life.  They  bear  no  relation  to  the  par- 
ovarium. In  some  cases  the  cysts  are  much  larger.  There  is  a  speci- 
men in  St.  George's  Museum  (No.  xiv,  130)  of  a  cyst  as  large  as  a 
walnut. 

Carcinoma  occurs  as  an  extension  of  the  same  disease  from  the 
uterus  or  ovaries.  Kiwisch  once  saw  a  case  in  which  the  tube  burst 
from  distension  of  the  walls  with  cancerous  tissue. 

Tubercle  most  frequently  occurs  in  association  with  tuberculous  de- 
posit in  the  uterine  cavity;  but  it  may  occur  in  the  tubes  alone.  Such 
a  case  is  preserved  in  St.  Thomas's  Hospital  Museum.  The  tube  is 
there  filled  with  a  cheesy,  soft  mass ;  the  tube  is  swollen,  distended,  re- 
sembling in  outward  form  the  distension  from  fluids.  Generally  both 
tubes  are  symmetrically  affected. 

Rokitansky  says  tubal  tuberculosis  generally  occurs  as  a  primitive 
affection,  and  is  afterwards  complicated  with  tubercle  of  the  abdominal 


DISEASES    OF     FALLOPIAN    TUBES.  351 

glands.  It  is  also  associated  with  tubercle  of  the  lungs  and  mucous 
membrane  of  the  intestinal  canal. 

It  appears  sometimes  in  childhood,  sometimes  in  the  age  of  decrepi- 
tude, but  usually  in  the  period  of  puberty.  Often  it  becomes  devel- 
oped in  consequence  of  childbed.  Rarely,  the  tuberculous  mass  goes 
into  calcification. 

In  St.  George's  Museum  are  two  specimens  of  "scrofulous  disease" 
affecting  the  mucous  lining  of  the  uterus  and  tubes.  In  one,  both  ova- 
ries were  also  affected,  "  containing  the  remnants  of  a  semi-fluid  tuber- 
cular matter ;"  in  the  other,  one  ovary  was  converted  into  an  abscess 
containing  scrofulous  pus.  Both  had  tuberculosis  of  other  organs  as 
well. 

Two  specimens  in  Guy's  Museum  (jSTos.  2251  and  2251"^)  show 
tuberculous  matter  in  the  tubes  of  children.  One  of  the  children  died 
of  strumous  inflammation  of  the  brain.  There  were  also  tubercles  in 
the  lungs.  But  it  may  happen  that,  although  tubercle  in  the  Fallopian 
tubes  is  generally  of  secondary  importance  as  a  cause  of  death,  the  func- 
tion of  the  tube  being  of  little  comparative  moment,  the  disease  in  this 
part  may  be  the  immediate  cause  of  death.  Perforation  of  the  tube 
may  outstrip  the  fatal  march  of  tubercle  in  the  lung.  Specimen  No. 
2251^°  in  Guy's  Museum  exhibits  "  the  tubes  and  ovaries  invested  in 
adventitious  tissue,  forming  part  of  a  general  tubercular  peritonitis. 
The  tubes  were  greatly  distended  with  thick  white  grumous  matter. 
The  subject,  aged  twenty-two,  died  of  phthisis  and  peritonitis." 

Fibroid  tumors,  or  myomas,  similar  in  character  to  the  tumors  so 
named,  of  the  uterus,  may  occur  in  the  Fallopian  tubes,  Baillie  de- 
scribes "a  hard  tumor  growing  from  a  Fallopian  tube,  which  exhibited 
precisely  the  same  appearances  as  the  hard  tubercle  (fibroid)  of  the 
uterus."  They  are  developed  out  of  the  muscular  coat.  They  may 
attain  a  considerable  size.  Professor  Simpson  describes  one  as  large  as 
a  child's  head;  but  probably  this  was  of  exceptional  size.  They  are 
rare,  or,  at  least,  have  been  rarely  identified  as  distinct  from  uterine 
fibroids  or  solid  ovarian  tumors.  Arising  on  one  side  of  the  uterus, 
that  is,  in  a  situation  very  close  to  that  of  ovarian  tumors,  and  being 
at  first  movable,  the  difficulty  of  discrimination  must  be  almost  insur- 
mountable during  life.  And  even  after  death  there  is  room  for  doubt, 
for  a  fibroid  tumor,  taking  its  origin  in  the  external  strata  of  the  uterine 
wall,  may  be  gradually  cast  off  so  completely  that  the  pedicle  even  be- 
comes atrophied  and  no  longer  traceable ;  the  detached  tumor  then  may 
lie  between  the  folds  of  the  broad  ligament  in  such  close  proximity- 
with  the  tube,  that  appearances  may  support  the  idea  that  this  was  its 
true  origin.  They  would  differ  from  ovarian  tumors  in  their  progres- 
sion. Comparatively  inert,  they  annoy  chiefly  by  mechanical  pressure; 
they  may  get  jammed  in  the  pelvis,  and  displace  the  uterus,  and  press 
upon  bladder  or  rectum.  If  of  large  size,  and  situated  above  the 
pelvic  brim,  their  bulk  and  weight  would  cause  inconvenience,  perhaps 
peritonitis.  In  the  event  of  symptoms  severe  enough  to  indicate  the 
expediency  of  removing  the  tumors,  the  operation  as  for  ovariotomy 
might  be  performed,  with  a  fair  prospect  of  success.     It  is  also  possible 


352  FALLOPIAN    TUBES. 

that  small  ones  dipping  low  in  the  pelvis  by  the  side  of  the  uterus 
might  be  removed  by  the  vagina. 

Anomalies  of  size,  that  is,  of  calibre  and  length. 

The  tube  mav  undergo  elongation  to  a  greater  or  less  extent  tliroiigh 
dragging  of  the  uterus,  as  in  prolapsus ;  or  upwards,  as  when  enlarged 
bv  fibroid  tumors.  But  the  most  marked  elongation  is  produced  bv 
the  dragging  of  an  ovarian  tumor.  In  this  case  the  whole  tul^e  be- 
comes hypertrophied,  its  canal  is  widened,  especially  towards  its  fim- 
briated extremity,  which  sometimes  stretches  out,  grasping  a  large  sur- 
face of  the  tumor.  Sometimes  the  stretching  of  the  tube  produces  a 
marked  thinning  at  one  part,  which  undergoes  atrophy. 

The  dilatation  of  the  tube  is  produced  by  accumulations  of  mucus  and 
of  pus,  which,  when  the  two  ends  are  closed,  constitute  in  its  extreme 
states  hydrops  tubce.  This  affects  more  especially  the  outer  end  of  the 
tube.  It  may  also  be  dilated  by  collections  of  blood,  and  notably  by 
the  development  of  an  ovum  in  it.  Deposits  of  tubercular  matter  also 
produce  dilatation.  In  all  these  cases,  excepting  that  of  gestation,  the 
form  assumed  by  the  tube  is  very  similar.  The  accumulation  and  dis- 
tension take  place  along  the  greater  part  of  the  length  of  the  tube,  so 
that  there  is  formed  a  vermiform  or  contorted  cylindrical  or  conical 
swelling,  the  greater  calibre  of  the  swelling,  or  its  base,  being  usually 
towards  the  fimbriated  end.  Both  tubes  are  commonly  aifected  alike. 
In  this  enlarged  state  they  find  no  room  in  their  natural  place  in  the 
sides  of  the  pelvis;  they  therefore  rise  out  of  the  brim  of  the  pelvis, 
and  get  directed  somewhat  forward  towards  the  groins,  occupying  the 
hypogastric  space.  They  may  then  be  felt  behind  and  above  Poupart's 
ligament.  Sometimes,  however,  they  get  imprisoned  in  the  upper  part 
of  the  pelvis  by  adhesions. 

The  dilatation  or  enlargement  of  the  calibre  of  the  tubes  is  a  subject 
of  great  importance  in  its  relation  to  the  practice  of  injecting  fluids 
into  the  uterus.  It  so  haupens  that  some  of  the  morbid  processes  which 
give  indications  for  injecting  styptic  or  astringent  fluids  into  the  uterus, 
also  entail  undue  patency  of  the  uterine  mouths  of  the  tubes  and  of  the 
tubes  themselves.  The  mechanism  by  which  this  patency  is  produced, 
as  well  as  the  morbid  processes  which  bring  this  mechanism  into  action, 
are  therefore  of  special  interest.  We  may  take  as  a  t}'pe  a  case  of  dys- 
menorrhoea  from  obstruction  at  some  point  of  the  uterine  canal,  as  at 
the  OS  internum  1)y  flexion.  In  such  a  case  there  is,  as  I  have  ex- 
plained under  "Atresia,"  a  degree  of  retention  of  menstrual  fluid, 
asTorravated  bv  formation  of  clots.  The  retained  matters  irritate  the 
uterus,  excite  reflex  action,  and  thus  cause  uterine  colics  or  exi)ulsive 
pains;  that  is,  the  body  of  the  uterus  contracts,  trying  to  expel  its  con- 
tents. There  is  obstruction  at  the  natural  outlet;  hence,  following  the 
general  dilatation  of  the  uterine  cavity,  there  is  retrograde  dilatation  of 
the  uterine  mouths  of  the  tubes.  All  this  is  seen  in  a  marked  degree 
in  cases  of  complete  retention;  but  I  believe  ii  is  rarely  absent  in  a 
minor  degree  in  cases  of  partial  retention.  The  pathological  and  thera- 
peutical consequences  of  this  state  are:  secretions  of  blood,  mucus,  or 


INFLAMMATION.  353 

pus  formed  in  the  uterus  may  be  driven  backwards  by  the  contraction 
of  the  uterus  along  the  tubes,  distending  the  tubes,  exciting  inflamma- 
tion in  them,  and  perhaps  leading  to  discharge  into  the  peritoneal 
cavity.  In  a  similar  manner  fluids  injected  into  the  uterus  excite  con- 
traction, and  this  contraction  drives  the  fluid  along  the  tubes,  if  its 
exit  be  impeded  at  the  neck,  either  by  flexion,  or  by  the  canal  being 
filled  too  closely  by  the  injecting-tube. 

This  accident  may  be  avoided  by  the  use  of  remedies  in  a  solid  form 
or  as  ointments,  or  of  fluids  carried  on  a  swab. 

Dr.  Matthews  Duncan^  refers  to  this  condition.  He  passed  a  probe 
with  the  least  possible  pressure,  feeling  certain  that  it  went  beyond  the 
uterus;  it  always  took  a  decidedly  lateral  direction.  He  concluded 
that  it  must  have  passed  through  a  dilated  tube  into  the  abdominal 
cavity. 

The  tube  is  liable  to  inflammation — salpingitis — and  suppuration, 
independently  of  childbed.  This  may  extend  from  the  uterine  cavity  ; 
and  this,  according  to  Scanzoni,  is  its  common  origin.  But  it  may 
arise  in,  and  be  confined  to,  the  tube.  Aran  relates  a  case  of  suppura- 
tion of  both  ovaries  and  tubes,  supervening  on  menstrual  disturbance, 
without  metritis.  When  suppuration  occurs,  the  collection  of  pus  pro- 
duces similar  eflfects  upon  the  form  of  the  tube  as  other  fluids.  It  does 
not  escape  readily  by  either  end,  but  being  retained  and  accumulating, 
forms  a  cylindrical,  somewhat  tortuous,  dilatation  of  the  middle  part 
of  the  tube.  Then  comes  the  special  danger  attending  distension.  The 
tube  may  burst,  or  be  perforated,  and  oifending  matter,  in  sufficient 
quantity  to  irritate  the  peritoneum,  suddenly  escapes  into  the  abdomi- 
nal cavity.  Peritonitis  may  result  from  salpingitis  in  three  ways:  1, 
by  extension  of  inflammation  through  the  fimbriated  end;  2,  through 
perforation  of  the  tube ;  3,  through  pouring  of  pus  through  the  open 
end. 

The  physical  signs  Avill  be  the  same  as  those  of  dropsy  of  the  tube. 
There  will  be  similar  fluctuating,  bent,  cylindrical  rolls  felt  behind 
Poupart's  ligament,  and  in  the  vaginal  roof.  The  diagnosis  is  very 
important,  because  this  condition  must  fall  under  the  same  rule  of 
treatment  by  puncture  as  other  affections  of  the  tube,  namely,  tubal 
gestation  and  dropsy. 

Fig.  80,  after  Hooper,  is  a  good  illustration  of  inflammation  of  both 
tubes.  It  shows  the  immediate  effects  of  acute  inflammation  of  the 
mucous  membrane.  The  peritoneal  investment  is  very  vascular.  The 
substance  of  the  tube  is  much  thickened  and  softened,  and  dilated  into 
a  sac.  The  mucous  surface  is  covered  with  a  flocculent  albuminous 
layer.  A  quantity  of  fluid  albumen  escaped  when  the  sac  was  opened. 
The  fimbriae  are  destroyed  ;  and  the  openings  into  the  cavity  of  the 
abdomen  are  obliterated. 

Tubal  catarrh  is  probably  most  commonly  the  result  of  extension  of 
inflammatory  action  from  the  uterine  cavity.  This  may  be  acute  or 
chronic.     The  acute  form  may  be  due  to  blennorrhoea.     The  chronic 

1  "  On  a  hitherto  undescribed  disease  of  the  uterus,  namely,  unnatural  patency  of 
the  Fallopian  tube."— Edin.  Med.  Journ.,  1856. 

23 


354 


FALLOPIAN    TUBES. 


form  may  result  from  the  acute,  or  it  may,  ah  origine,  have  been  of  a 
subacute  kind.  Catarrhal  inflammation  of  the  uterus  and  tubes  entails, 
for  one  of  its  eifects,  a  degree  of  laxity  of  tissue  and  dilatation  of  cavity, 
as  the  mucus  formed  in  the  tube  will  naturally  tend  to  discharge  itself 
into  the  uterine  cavity,  and  commonly  this  action  is  favored  by  the 
dilatation  of  the  ostium  uterinum.  If  escape  by  the  ostium  abdominale 
were  common,  catarrh  would  be  a  very  dangerous  affection.  As  it  is, 
accumulations  in  the  tube  rarely  take  this  route.  It  is  only  when  the 
fluids  secreted  are  large  in  quantity,  formed  rapidly,  as  in  blennorrhoea, 
that  the  risk  of  retrograde  overflow  is  serious.  But  when  the  openings 
of  the  tubes  are  obstructed,  the  fluids  accumulate  and  distend  them, 


Inflammation  of  the  Fallopian  tubes  (half-size). — (After  Hooper.) 
a.  Uterus.  6  b.  Tubes.  c  c.  Saccular  dilatations  laid  open. 

and,  by  and  by,  perforation  or  bursting  takes  place.  This  closure  is 
easily  produced.  At  the  outer  end,  catarrhal  inflammation  often  leads 
to  adhesions  of  the  fimbriae;  and,  at  the  inner  end,  the  swelling  of  the 
tubes  contorting  it,  forms  angular  spurs  or  valve-like  bendings,  which 
shut  off  the  communication  with  the  uterus. 

There  is  no  reason  to  doubt  that  the  lining  membrane  of  the  tubes 
is  liable  to  inflammation  which  may  lead  to  suppuration.  The  gonor- 
rhoea! inflammation  is  an  example  of  this.  But  it  must  be  remembered, 
that  in  the  tubes,  as  well  as  in  the  uterus  and  vagina,  fluids  may  ac- 
cumulate which  the  naked  eye  could  not  distinguish  from  pus,  and 
which,  on  microscopical  analysis,  is  resolved  into  epithelium  scales  float- 
ing in  plasma.  This  was  the  case  in  a  young  woman  who  died  of  chorea 
in  St.  George's  Hospital.  The  vesicles  of  the  ovaries  contained  coagula. 
The  Fallopian  tubes  were  full  of  milky  fluid,  like  pus,  which  proved 
to  consist  of  columnar  epithelium.^  This  fact  must  be  borne  in  mind 
in  estimating  the  significance  of  puriform  matter  in  the  tubes. 

The  tubes  may  be  distended  by  accumulations  of  blood.  One  cause 
of  this  is  menorrhagia.     Usually,  the  uterine  opening  gives  it  passage; 

'  See  Catalogue,  St.  George's  Museum,  XIV,  No.  5. 


H^.MATOMA.  355 

but  sometimes,  if  this  opening  be  obstructed,  as  by  a  clot,  the  blood 
continuing  to  be  poured  out  by  the  tubal  mucous  membrane  may  over- 
flow by  the  abdominal  end,  and  give  rise  to  retro-uterine  haematocele. 
The  like  event  may  occur  in  the  hemorrhage  of  abortion.  Another  form 
of  blood-accumulation,  and  one  especially  dangerous,  is  that  which  re- 
sults from  atresia,  or  closure  of  the  uterus,  vagina,  or  vulva,  leading  to 
retention  of  the  menstrual  fluid.  The  Fallopian  tubes  in  these  cases 
commonly  undergo  extreme  dilatation,  and  are  liable  to  bursting  or 
perforation.     This  subject  is  discussed  more  fully  under  "  Atresia." 

In  other  cases  the  obstruction  takes  place  at  the  ostium  uterinum. 
When  this  occurs,  it  does  not  follow  that  the  tubes  will  give  up  their 
part  in  the  function  of  menstruation  ;  blood  will  be  poured  out  into  the 
tubes,  and,  if  it  do  not  escape  by  the  ostium  abdominale,  must  accumu- 
late as  tubal  retention.  When  we  look  at  the  contorted  shape  of  the 
tube,  it  is  not  difficult  to  conceive  how  easily,  under  distension  of  one 
part  of  the  tube,  further  contortion,  producing  angular  flexion,  may 
occur,  so  as  to  shut  in  the  contents.  The  closure  at  the  extremities  of 
the  tubes,  especially  of  the  abdominal  extremity,  is  further  very  likely 
to  be  effected  by  inflammation  of  the  tube  and  peritoneal  investment. 
This  inflammation  may  by  caused  by  a  minute  perforation  under  an 
ulcerative  process,  permitting  a  little  of  the  retained  fluid  to  escape  into 
the  peritoneum;  or  it  is,  I  believe — although  there  is  no  distinct  clini- 
cal proof  of  this — more  likely  to  happen  through  transudation,  or  oozing 
through  the  walls  of  the  tube  under  the  combined  pressure  of  ac- 
cumulation and  the  excited  contractile  efforts  of  the  walls  of  the  tube. 
The  contact  of  the  unhealthy  moisture  thus  bedewing  the  peritoneum 
would  be  pretty  sure  to  set  up  inflammation  in  this  susceptible  mem- 
brane. 

But  retention  of  blood  or  mucus  in  dilatations  of  the  tubes  may  ter- 
minate in  another  way.  Peritonitis  may  or  may  not  supervene ;  after 
a  time  there  is  no  further  increment  of  blood  or  mucus  ;  the  watery 
part  of  that  already  in  the  tube  may  be  absorbed,  and  the  tube,  not  re- 
covering its  pristine  form,  may  assume  the  condition  of  cysts. 

There  is  a  good  illustration  of  cystiform  dilatation  of  both  tubes  from 
tubal  menstrual  retention  in  the  "  Obstetrical  Transactions,"  vol.  viii, 
described  by  Dr.  Meadows.  The  history  of  the  subject  is  interesting. 
She  had  had  fifteen  pregnancies,  but  only  one  had  gone  on  to  term ; 
menstruation  had  generally  been  profuse,  and  latterly  became  clotty 
and  painful.  She  died  of  extensive  peritoneal  inflammation,  involving 
the  uterus  and  tubes.  The  tubes  presented  cystiform  dilatations ;  no 
communication  Avas  found  between  these  dilatations  and  the  fimbriated 
extremities,  and  on  the  left  side  the  ostium  uterinum  was  quite  closed. 
The  dilatations  were  "  all  filled  with  a  dark,  thick,  grumous  fluid  of  a 
prune-juice  color."  This  resembled  the  retained  menstrual  blood  in  the 
uterus,  and  was  no  doubt  of  like  origin. 

Wagner'  describes  a  case  of  hasmatonia  of  the  Fallopian  tube.  There 
was  also  an  old  blood-mass  in  the  pelvis,  ft)und  after  death.     The  tube 

1  Monatssehrift  fiir  Geburtskunde,  1869. 


356  FALLOPIAN    TUBES. 

was  dilated  only  at  the  seat  of  the-  hsematoma.     There  was  nothing 
abnormal  in  the  ovary  or  uterus. 

It  seems  probable  that  the  closure  of  the  tube  at  the  uterine  end  or 
at  the  fimbrise  is  one  of  the  dangers  of  gonorrhoea,  or  of  those  attacks 
of  metritis  or  peritonitis  to  which  prostitutes  are  so  subject.  These 
attacks,  which  give  rise  to  the  symptoms  known  as  colica  scortorum, 
commonly  involve  the  tubes  as  well  as  the  ovaries.  Closure  of  the 
tubes  almost  necessarily  is  the  first  condition  of  retention,  and  thence  of 
hemorrhagic  and  dropsical  accumulations. 

Drojjsy  of  the  tube  is  probably  a  secondary  phenomenon  of  various 
affections,  as  of  inflammation  or  effusion  of  blood.  Effusions  cause 
distension  ;  these  being  preceded  or  followed  by  closure  of  the  extrem- 
ities of  the  tubes,  saccular  dilatations  readily  form,  and  the  outlets 
being  closed,  sacs  of  considerable  size  may  form.  Baillie  describes 
"  dropsy "  of  the  tube,  and  quotes  Portal  as  having  referred  to  it. 
Baillie  says  the  tube  terminated  in  a  cul-de-sac.  Hooper  gives  an 
excellent  engraving  of  a  case  which  exhibits  very  clearly  the  charac- 
teristic contortions  and  dilatations  of  the  tubes,  the  maximum  of  dila- 
tation being  on  both  sides  at  the  abdominal  end.  Both  tubes  are 
generally  symmetrically  affected,  although  unequally.  The  cyst  is  not 
necessarily  single,  but  may  be  subdivided  by  tight  fibrinous  bands,  the 
product  of  peritonitis,  encircling  and  constricting  the  tube  at  various 
points.  The  muscular  wall  is  thickened.  The  mucous  membrane  is 
changed  from  its  natural  appearance;  it  becomes  smooth  or  roughened 
by  papillary  vegetations  from  the  submucous  connective  tissue. 

In  many  of  these  cases  the  disease  is  only  recognized  by  dissection, 
death  being,  in  some  instances,  brought  about  by  other  causes. 

The  contents  of  the  tube  may  be  mucous,  purulent,  watery,  sanguin- 
eous, like  serum,  or  thick.  Boinet  says  he  found  in  a  Fallopian  tube 
thirteen  pounds  of  water  mixed  with  pus.  Simpson,  recalling  the 
intimacy  and  extent  of  the  adhesions  often  formed  with  the  ovary,  and 
the  ease  with  which  the  diseases  of  the  tube  may  thus  be  confounded 
with  those  of  the  ovary,  doubts  the  accuracy  of  Boinet's  conclusion. 

The  quantity  of  fluid  which  constitutes  the  hydrops  tubce  is  not  usu- 
ally very  great,  but  Dr.  Peaslee'  relates  a  case  in  which  the  patient 
had  been  tapped  twice  for  ovarian  dropsy,  in  whom  there  was  found 
on  the  right  a  true  ovarian  cyst,  and  on  the  left  a  tumor  of  the  Fal- 
lopian tube  of  very  large  size.  The  tube  had  become  occluded  at  the 
very  commencement  of  the  uterus ;  accumulation  took  place  beyond, 
until  the  tube  was  distended  into  a  sac  with  the  capacity  of  eighteen 
pounds.     The  whole  was  adherent  to  everything  in  its  neighborhood. 

Sometimes  dropsy  of  the  tubes  is  associated  with,  probably  depend- 
ent upon,  general  dropsy,  as  in  a  case,  No.  2254*^,  in  Guy's  Museum. 
This  specimen  shows  the  uterus  and  appendages.  The  right  Fallopian 
tube  is  greatly  dilated.  It  came  from  a  woman,  aged  forty-five,  ad- 
mitted for  renal  dropsy. 

In  a  considerable  number  of  cases,  obstruction  at  the  uterine  orifice 
of  the  tube,  as  by  a  fibroid  tumor,  seems  to  have  been  the  cause  of  ac- 

1  New  York  Medical  Journal,  1870. 


D  E  O  P  S  Y.  357 

cumulation  of  jfluid  in  the  tubes.  This  is  seen  in  specimens  Nos.  866, 
University  College,  and  2643,  Royal  College  of  Surgeons.  No.  2261^, 
in  Guy's  Museum,  shows  "  a  fibrous  tumor  of  the  uterus.  Dr.  Oldham 
dilated  the  os  to  get  at  the  tumor.  Whilst  under  treatment,  the  patient 
was  seized  with  acute  peritonitis,  and  died.  An  abscess  in  the  left  tube, 
in  which  the  ovary  was  involved,  had  burst." 

The  symptoms  produced  by  dropsy  of  the  tube  resemble  those 
arising  from  other  enlargements  of  the  tube  or  ovary  up  to  a  certain 
point.  There  is,  says  Simpson,  an  uneasy  sense  of  weight  in  the  side 
affected,  and  a  feeling  of  pressure  in  the  limb ;  usually  the  limb  is 
rendered  more  or  less  numb  from  the  pressure  of  the  tumor  on  the 
nerves  passing  through  the  pelvis,  and  this  may  even  extend  to  lame- 
ness, as  in  pelvic  cellulitis.  In  some  cases  the  swelling  acts  chiefly  on 
the  bowels,  keeping  them  loaded.  More  rarely  there  is  a  certain  de- 
gree of  dysuria.  Intercurrent  at  some  period  of  the  history,  signs  of 
local  peritonitis  will  probably  appear. 

Diagnosis. — Dilatation  of  the  Fallopian  tube  may  be  diagnosed  from 
small  cystic  enlargement  of  the  ovary  by  the  shape  of  the  tumor,  its 
position,  and  by  its  relation  to  the  uterus. 

It  is  of  essential  importance  to  clear  the  way  by  emptying  the  blad- 
der, and  by  determining  the  exact  position  of  the  uterus  by  the  sound. 

A  small  cyst  of  the  ovary  gets  behind,  and  a  little  to  one  side  of 
the  uterus,  pushing  the  uterus  forwards  against  the  symphysis,  pro- 
ducing probably  irritation  of  the  bladder  or  retention  of  urine ;  there 
is  only  slight  obliquity  imparted  to  the  uterus.  The  shape  of  the 
tumor  is  more  or  less  spherical.  It  is  felt  better  by  the  rectum  than 
in  the  roof  of  the  vagina. 

Fluid  distension  of  the  tube  produces  an  elongated,  contorted,  cylin- 
drical swelling.  Its  position  is  more  forward  than  that  of  the  ovary ; 
it  does  not,  therefore,  push  the  uterus  forward,  but  pushes  the  fundus 
towards  the  opposite  side ;  there  is  greater  obliquity  of  the  uterus.  The 
swelling  also  may  commonly  be  felt  behind  Poupart's  ligament,  and 
can  be  defined  between  the  hand  outside  and  the  finger  in  the  vagina. 
Vaginal  touch  will  enable  the  observer  to  detect  the  swelling  on  one 
side  of  the  cervix  uteri. 

Except  in  the  case  of  tubal  gestation,  affections  of  the  tube  are  com- 
monly symmetrical,  that  is,  both  tubes  are  alike  distended.  This 
condition  itself  would  be  greatly  diagnostic  from  ovarian  disease,  which 
is  not  nearly  so  often  double,  and  very  rarely,  indeed,  symmetrical, 
one  ovary,  where  both  are  affected,  being  more  advanced  in  disease  than 
the  other.  When  both  tubes  are  involved,  they  will  keep  the  uterus 
straight  between  them,  and  a  cylindrical  contorted  roll  will  be  felt  on 
either  side. 

Fig.  81  gives  an  ordinary  form  of  the  dropsical  tube.  It  comes  from 
a  girl,  aged  nineteen.  Both  tubes  are  tortuous,  and  each  forms  an 
elongated  and  somewhat  conical  cyst.  The  dilatation  begins  about  an 
inch  and  a  half  from  the  uterus,  and  gradually  increases  until  it  attains 
a  diameter  of  an  inch.  The  parietes  are  thinned  in  proportion  to  the 
dilatation.  The  fimbriated  extremities  have  become  adherent  to  the 
ovaries  and  other  parts,  and  thus  have  become  closed.     In  the  living 


358 


FALLOPIAN    TUBES. 


subject  these  distended  tubes  would  occupy  the  iliac  fossae,  lying  in  a 
right  line  with  the  fundus  uteri. 

Another  specimen  in  the  same  museum,  No.  FF  55,  shows  each  tube 
dilated  into  a  globular  cyst.  The  cyst  on  the  right  side  was  filled  with 
bloody  fluid,  and  some  laminated  coagula  still  remain  adherent  to  its 
upper  part.  The  other  cyst  is  distended  with  white  fatty  matter,  con- 
tained in  numerous  cells.    The  tubes  at  a  short  distance  from  the  uterus 


Dropsy  of  Fallopian  tube,  nat.  size.    (St.  Thomas's  Museum.) 


are  completely  clo.sed.  The  uterus  is  healthy.  The  specimen  was 
taken  from  a  woman,  aged  twenty-one,  of  dissipated  habits,  who  died 
of  phthisis. 

The  treatment  of  dropsical  distension  of  the  Fallopian  tubes  consists 
simply  in  puncturing  the  cysts  through  the  vaginal  roof.  If  a  tense 
fluctuating  swelling  be  found  in  this  region  attended  by  local  distress, 
there  ought,  I  think,  to  be  no  hesitation  in  tapping  it  by  the  aspirator- 
trocar.  This  instrument  combines  in  a  high  degree  the  merits  of  the 
sound  and  speculum,  namely,  in  being  diagnostic  and  curative.     The 


TREATMENT    OF    MORBID    CONDITIONS.  359 

range  of  liability  to  error  in  diagnosis  lies  between  dropsy  of  the  tube, 
cysts  of  the  broad  ligament,  cysts  of  the  ovary,  cyst  containing  an 
extra-uterine  gestation.  Now,  in  all  these  cases,  the  same  indication 
exists  to  puncture  the  cyst,  so  that  absolute  precision  of  differential 
diagnosis  is  not  imperative.  The  diagnosis  may  become  clearer  after 
the  tapping.  Thus  if  the  cyst  be  tubal,  or  in  the  broad  ligament,  it  is 
not  likely  to  fill ;  there  is  reasonable  prospect  of  complete  cure.  But 
if  the  cyst  be  ovarian,  it  is  not  unlikely  to  fill  again.  The  mode  of 
operating  is  described  under  the  "  Treatment  of  Early  Ovarian  Dropsy." 
An  incidental  consequence  of  most  morbid  conditions  of  the  Fallo- 
pian tubes  is  sterility.  There  may  be  mechanical  obstruction  to  the 
passage  of  the  ovum  and  spermatozoa ;  or,  if  the  canal  be  pervious, 
the  condition  of  the  lining  membrane  or  of  the  secretions  in  it  may  be 
destructive  to  the  vitality  of  the  male  and  female  elements.  Another 
incidental  consequence,  we  shall  see,  is  the  proneness  to  extra-uterine 
gestation. 

The  Treatment  of  Morbid  Conditions  of  the  Fallopian  Tubes. 

Salpingitis  being  generally  a  part  of  an  inflammatory  process,  of 
which  the  chief  seat  is  the  cavity  of  the  uterus,  the  treatment  merges 
in  that  which  is  indicated  for  the  principal  affection.  If  it  lead  to  the 
escape  of  irritating  matters  or  blood  into  the  peritoneum  by  rupture, 
perforation,  or  overflow,  the  case  must  be  treated  on  the  principles  laid 
down  when  discussing  the  subjects  of  Menstrual  Retention  and  Tubal 
Gestation.  The  secret  of  preventing  many  of  the  tubal  diseases,  and 
of  curing  some,  lies  in  securing  patency  of  the  uterine  ends. 

But  there  are  points  of  special  interest  in  the  dealing  with  tubal  dis- 
tension. We  know  the  danger  of  rupture,  perforation,  or  overflow. 
We  know  that  this  danger  is  averted  or  greatly  lessened,  if  the  con- 
tents of  the  tube  can  be  evacuated  by  the  natural  route  into  the  uterus. 
Can  nothing  be  done  to  turn  the  discharges  into  this,  their  natural 
drain?  To  accomplish  this  object.  Dr.  Tyler  Smith  proposed  "Fallo- 
pian catheterization.''  He  devised  and  demonstrated  the  practicability 
of  passing  a  fine  whalebone  probe  into  the  tube.  The  proposition  when 
originally  made,  and  since,  encountered  considerable  criticism ;  it  was 
said  to  be  rash,  dangerous,  and  impossible  of  execution.  The  real  ob- 
jection is  that  it  is  new  and  difficult.  I  think  the  operation  will  be 
established  in  spite  of  the  ridicule  and  the  arguments  aimed  against  it; 
and  that  the  difficulties  of  diagnosing  the  cases  proper  for  its  applica- 
tion, as  well  as  of  carrying  it  into  execution,  will  be  greatly  lessened. 
Many  of  the  reasons  which  are  recognized  as  justifying  catheterization 
of  the  uterus,  apply  to  catheterization  of  the  tubes.  The  obstacle  to 
the  onward  discharge  of  mucus  or  pus  from  the  tube  commonly  exists 
in  the  uterine  portion,  which  is  naturally  contracted,  and  may  be 
occluded  by  a  plug  of  clotted  blood  or  condensed  mucus  or  pus.  A 
very  slight  force  would  remove  this  impediment,  and  the  passage  of  a 
flexible  probe  through  this  part  would  not  be  difficult.  Whether  it 
would  be  easy  or  feasible  to  pass  a  probe  to  any  considerable  distance 
along  the  canal,  following  its  sinuosities,  is  a  matter  for  experience  to 


360  CYSTS     OF    THE    BEOAD     LIGAMENT. 

determine.  It  will,  I  think,  rarely  be  necessary.  I  can,  indeed, 
imagine  that  a  tubal  gestation-sac  might  be  ruptured  in  this  way,  and 
the  gestation  so  brought  to  an  end.  But,  as  will  be  shown  when  treat- 
ing of  tubal  gestation,  the  tapping  of  the  sac  may  be  accomplished 
through  the  roof  of  the  vagina. 


CHAPTER  XXXV. 

THE  BEOAD  LIGAMENTS;  DROPSY;   INFLAMMATION;   PHLEG- 
MASIA DO  LENS;  PHLEBOLITHES;  FIBROID  TUMORS. 

The  principal  affections  of  the  broad  ligaments  are :  dropsy,  inflam- 
mation, and  obstruction  of  its  bloodvessels  and  lymphatics.  Inflammation 
will  be  more  conveniently  described  in  connection  with  pelvic  peri- 
tonitis and  cellulitis,  and  obstruction  of  the  vessels  in  connection  with 
phlegmasia  dolens. 

Dropsy  of  the  Broad  Ligament. 

Extra-ovarian  cysts,  or  cysts  of  the  broad  ligament  and  of  the  Fallo- 
pian tube,  are  chiefly  of  two  kinds.  One  kind  of  cyst  is  a  dilatation  of 
the  terminal  bulb  or  vesicle  of  the  Fallopian  tube  (see  Fig.  2,  p.  21). 
In  the  form  and  size  figured,  they  cannot  be  called  pathological.  They 
rarely  exceed  in  size  that  of  a  pea  or  nut,  but  occasionally  are  found  as 
large  as  an  egg.  They  usually  have  thin  walls,  are  covered  by  peri- 
toneum, and  hang  by  a  long  slender  pedicle.  They  may  probably 
burst,  but  the  small  quantity  and  innocent  nature  of  their  contents  in- 
duce no  great  irritation  in  the  peritoneal  cavity. 

The  other  variety  of  cyst  is  found  between  the  folds  of  the  broad 
ligament,  at  least  in  its  original  stages.  It  is  a  development  of  the 
tubules  of  the  parovarium  (see/,  b,  Fig.  2,  p.  21).  These  cysts  occa- 
sionally grow  larger  than  the  so-called  terminal  hydatid  of  the  Fallo- 
pian tube.  They  may  even  grow  as  large  as  a  man's  head,  and  indeed 
may  attain  the  full  dimensions  of  ovarian  cysts.  The  walls  may  be- 
come thickened  by  development  of  fibrous  tissue,  but  still  they  remain 
comparatively  thin ;  fluctuation  is  usually  very  distinct  in  every  direc- 
tion. As  these  cysts  are  strictly  simple  and  innocent,  and  not  likely  to 
fill  again  if  emptied,  there  is  no  sufficient  reason,  supposing  the  diag- 
nosis be  clear  or  even  presumptive,  for  subjecting  the  sufferer  to  the 


CYSTS     OF    THE     BROAD     LIGAMENT.  361 

grave  risk  of  an  operation  for  extirpation,  or  even  to  that  of  injecting 
tincture  of  iodine.  Simple  tapping  is  often  enough  for  their  cure. 
There  can  hardly  be  a  doubt  that  some  cases  of  presumed  cure  of 
ovarian  cysts  by  injections  of  iodine  or  by  vaginal  tapping  were  really 
cysts  of  the  broad  ligament.  At  least  I  have  no  doubt  that  such  was 
the  true  nature  of  some  cases  which  have  occurred  in  my  own  practice. 
The  possibility  of  a  cystic  dropsy  being  of  this  kind  dictates  the  ex- 
pediency of  executing  a  preliminary  tapping  in  cases  where  the  fluctu- 
ation is  very  free  and  universal. 

The  features  of  a  cyst  of  this  kind,  when  greatly  enlarged,  are  illus- 
trated in  a  case  operated  upon  by  Mr.  Wells.  "  A  lady,  aged  twenty, 
had  observed  an  increase  of  size  for  a  year.  The  abdomen  was  occu- 
pied with  a  fluctuating  tumor  which  extended  upwards  two  or  three 
inches  above  the  umbilicus.  The  uterus  was  far  backwards,  a  little  to 
the  left,  and  freely  movable;  the  right  side  of  the  vagina  was  de- 
pressed, giving  rise  to  the  impression  that  the  connection  was  with 
the  right  side  of  the  uterus  and  rather  close.  The  disease  gave  so  little 
uneasiness  that  all  interference  was  postponed  for  some  months.  In 
the  meantime  the  increase  had  been  rapid.  The  cyst  was  then  re- 
moved, and  the  adjacent  ovary  along  with  it,  as  it  felt  hard  and 
appeared  larger  and  more  corrugated  than  is  usual  in  unmarried 
women ;  though  from  its  being  quite  apart  from  the  tumor,  it  would 
have  been  easy  to  remove  the  cyst  and  leave  the  ovary.  The  pedicle 
was  not  thicker  than  a  finger.  Another  cyst,  the  size  of  a  walnut, 
in  the  left  broad  ligament  near  the  ovary,  was  laid  open  and  emptied. 
Dr.  Wilson  Fox  reported  the  removed  cyst  when  distended  as  about 
twice  the  size  of  an  adult  head.  The  Fallopian  tube  flattened  out  is 
seen  to  course  along  its  external  surface.  The  fimbriae  are,  however, 
non-adherent  and  distinct.  The  ovary  is  found  in  a  fold  of  the  broad 
ligament  distinct  from  the  tumor,  and  presenting  the  natural  appearance. 
It  contains  no  cysts.  The  cyst  itself  has  a  smooth  external  wall.  It 
is  lined  internally  by  a  flattened  polygonal  epithelium.  No  villous  or 
papillary  growths  can  be  discovered  on  its  inner  surface.  This  was  of 
a  delicate  rose  color.  The  vascularity  of  the  cyst  was  not  very  great. 
Xo  other  cysts  could  be  found  in  the  broad  ligament." 

Fibroid  tumors  or  fibro-myomas  may  be  developed  in  the  broad  liga- 
ments by  aberrant  growths  of  the  cognate  tissues  inclosed  between 
their  folds.  Some  tumors,  apparently  belonging  to  the  broad  ligament, 
may  really  have  had  their  origin  in  the  uterus,  from  whose  walls  they 
have  been  extruded. 

The  vessels  in  the  broad  ligaments  are  a  favorite  seat  of  phlebolithes, 
or  stony  transformation  of  blood-clots.  The  vessels,  slenderly  sup- 
ported by  the  flaccid  tissues  through  which  they  run,  liable  to  great 
variations  of  fulness  and  tension,  and  embraced  between  layers  of  peri- 
toneum extremely  liable  to  inflammation,  are  subject  to  dilatations  and 
formation  of  thrombi.  These  vary  in  size  from  that  of  a  pea  to  nearly 
that  of  a  cherry.  Undergoing  hardening  they  may  become  calcareous. 
As  in  the  case  figured  in  Carswell  (see  Fig.  91),  the  ensuing  obliter- 
ation of  the  vessels  may  lead  to  atrophy  of  the  uterus. 


362  EXTEA-UTEEINE    GESTATION. 


CHAPTER   XXXVI. 

EXTKA-UTERINE  GESTATIOiN" :  TUBAL;  OVARIAN;  TUBO-OVA- 
EIAN;  ABDOMINAL;  INTEESTITIAL;  ONE-HORNED  UTERINE 
GESTATION. 

Tubal  Gestation. 

Under  various  conditions  the  Fallopian  tube  may  rupture  or  be- 
come perforated,  when  its  contents  suddenly  thrown  into  the  peritoneal 
cavity  may  cajise  shock,  or  peritonitis,  and  death.  The  best  known  of 
these  conditions  is  the  tubal  form  of  extra-uterine  gestation.  The  ovum 
may  be  arrested  in  any  part  of  the  tube.  If  caught  in  the  fimbrise,  a 
sac  is  formed  partly  out  of  the  dilated  mouth  of  the  tube,  and  partly 
by  attachments  to  neighboring  structures,  especially  the  ovary,  thus 
forming  the  tubo-ovarian  gestation.  The  sac  in  this  case  usually  as- 
sumes a  rounded  shape.  If  the  ovum  be  caught  in  the  middle  of  the 
tube,  the  shape  of  the  sac  is  more  ovoid.  It  may  be  caught  in  the 
uterine  portion  of  the  tube,  and  the  gestation  is  then  called  "  intersti- 
tial" or  "intramural."  It  may  be  said,  generally,  that  the  sac  bursts 
the  earlier  the  nearer  its  seat  is  to  the  uterus.  Thus  the  tubo-ovarian 
sac  may  not  burst  until  near  the  ordinary  term  of  uterine  gestation ; 
whilst  the  tubal  sac  or  the  interstitial  sac  usually  bursts  at  dates  vary- 
ing from  six  weeks  to  three  months.  Kiwisch  saw  a  case  which  burst 
at  four  weeks.  Gestation  may,  however,  go  on  for  four,  five,  or  even 
six  months.     Spiegelberg  relates  one  case  in  which  it  went  to  term. 

The  tube,  although  consisting  of  a  mucous  and  a  muscular  coat  like 
the  uterus,  is  ill  adapted  to  keep  pace  in  growth  with  the  rapid  devel- 
opment of  the  ovum.  The  adaptation  is  not  simply,  as  in  the  case  of 
uterine  gestation,  obtained  by  growth  of  the  tube  -pari  passu  with  its 
contents;  the  tube  is  stretched  as  well ;  and  there  comes  a  time  when, 
the  stretching  exceeding  the  distensibility  of  the  tube,  the  sac  bursts, 
and  the  contents  escape  into  the  peritoneal  cavity.  Along  with  the 
ovum,  or  at  least  the  embryo — for  frequently  the  chorion  and  decidua 
remain  attached  to  the  sac — there  almost  invariably  is  poured  out  a 
large  quantity  of  blood,  which  proceeds  from  the  torn  vessels  of  the 
tube.  The  injury  sustained  is  a  compound  one.  There  is  the  trau- 
matic violence  attending  the  rent,  producing  shock ;  and  hemorrhage, 
producing  ansemia.  The  symptoms  are  also  twofold.  Shock  induces 
collapse.  There  is  sudden  intense  pain  following  on  a  sense  of  some- 
thing having  given  way  in  the  lower  part  of  the  abdomen.  The  im- 
mediate effects  of  the  shock  are  coldness,  prostration,  near  extinction 
of  the  pulse,  vomiting ;  deadly  pallor  supervenes,  and  in  a  short  time, 
often  not  exceeding  a  few  hours,  the  patient  dies.  To  this  assemblage 
of  symptoms  I  have  given  the  name  "Abdominal  Collapse."  It  is 
distinguished  from  the  collapse  which  attends  sudden  injury  or  rup- 


EXTEA-UTEEINE    GESTATION.  363 

tures  in  the  head  by  the  preservation  of  the  mental  facnlties,  and  from 
the  like  injury  in  the  chest  by  the  absence  of  that  terrible  anxiety  of 
respiration  which  marks  the  chest  collapse.  The  symptoms,  coming  as 
they  do  suddenly  and  destroying  a  woman,  who  up  to  the  moment  of 
the  attack  was  in  the  enjoyment  of  good  health,  have  often  given  rise 
to  the  suspicion  of  foul  play  by  poison  or  mechanical  violence.  If  the 
patient  survive  the  shock,  and  reaction  set  in,  the  signs  of  hemorrhage 
become  manifest;  the  anaemia  is  marked  by  the  pallor  of  the  body,  the 
w^hiteness  of  the  tongue,  lips,  and  conjnnctivte,  the  hemorrhagic  pulse, 
the  distension  of  the  lower  abdomen,  and  sometimes  by  semi-fluctuation 
in  a  mass  behind  the  uterus  in  Douglas's  pouch,  constituting  what  I 
have  ventured  to  call  a  cataclysmic  form  of  retro-uterine  lisematocele. 
Again,  at  this  stage  the  patient  is  likely  to  sink  under  the  exhaustion 
of  the  shock  and  loss  of  blood  combined.  But  if  she  survive  this 
stage,  she  has  still  a  third  and  formidable  danger  to  encounter.  This 
is  peritonitis.  It  usually  supervenes  rapidly.  A  few  hours'  time  is 
often  enough  to  light  up  almost  universal  peritonitis.  Intense  pain 
continues,  the  patient  can  hardly  bear  the  slightest  touch  or  the  weight 
of  the  bedclothes  on  the  abdomen  ;  the  abdomen  swells,  becomes  tense, 
the  pulse  is  rapid  and  small,  the  temperature  rises  two  or  three  degrees 
above  the  normal  standard,  the  countenance  puts  on  the  anxious  drawn 
expression  characteristic  of  abdominal  injury.  Still  the  case  may  issue 
in  recovery.  The  shock  and  liemorrhage  may  be  not  greater  than  the 
patient  can  bear,  and  the  inflammation  may  be  limited  to  the  pelvic 
peritoneum ;  plastic  lymph  may  be  so  thrown  out  as  to  surround  and 
encapsulate  the  blood-mass. 

When  the  physician  is  called  to  a  woman  suffering  from  an  injury  of 
this  kind,  reference  to  her  previous  history  for  the  purpose  of  diagnosis, 
is  but  trifling  in  the  presence  of  a  great  emergency.  Nice  diagnosis  of 
the  cause  of  the  injury  and  source  of  the  bleeding  w^ould  afford  little 
help  in  treatment.  The  present  state  of  the  sufferer  demands  all  our 
care.  Historical  investigation  may  be  postponed.  This  is  far  from 
saying  it  should  be  neglected.  What  we  want  is  such  a  perfect  knowl- 
edge of  the  nature  and  course  of  a  disease — and  tliis  remark  applies 
with  especial  force  to  the  case  under  discussion — as  will  enable  us  to 
detect  it  in  its  incipient  stages,  to  understand  the  changes  that  are  in 
progress,  and  thus  to  acquire  indications  for  treatment  in  anticipation 
of  the  disasters  which  attend  the  climax.  The  hints  we  get  that  a  tubal 
pregnancy  is  going  on  are  commonly  so  obscure  that  they  are  easily 
overlooked.  The  subject  herself  may  feel  no  disturbance  of  health,  or 
observe  no  sign  so  unusual,  as  to  lead  her  to  seek  medical  advice.  She 
may  be  satisfied  that  she  is  pregnant  in  the  ordinary  way.  The  phy- 
sician rarely  indeed  has  the  opportunity  of  studying  these  cases  during 
their  progress.  He  sees  only  the  catastrophe.  But  phenomena  some- 
times present  themselves  which,  although  not  conclusive  as  to  the  ex- 
istence of  tubal  gestation,  are  yet  sufficiently  important  to  dictate  a 
careful  local  examination.  I  will  not  insist  upon  the  suspension  of 
menstruation,  and  the  presence  of  the  common  subjective  signs  of  preg- 
nancy, further  than  to  call  to  mind  that  if  examination  of  the  uterus 
lead  to  the  conclusion — and  this   is  not  easy  to  arrive  at — that  the 


364  EXTEA-UTERINE     GESTATION. 

uterus  is  not  the  seat  of  the  presumed  pregnancy,  we  should  consider 
the  possibility  of  an  extra-uterine  pregnancy.  One  difficulty  in  gain- 
ing the  first  step  in  diagnosis — that,  namely,  of  excluding  uterine 
pregnancy — lies  in  the  fact  that  the  developmental  force  working  in  the 
tube  extends  to  the  uterus,  causing  considerable  enlargement  of  this 
organ.  Another  obstacle  is  imposed  by  the  hypothesis  of  pregnancy, 
which  forbids  the  use  of  the  uterine  sound. 

Two  signs,  singly  or  concurrently,  justify  exploration.  These  are 
pain  and  hemorrhage.  These  signs,  of  course,  are  far  more  likely  to 
be  connected  with  ordinary  abortion,  some  disease  of  the  uterus,  or 
with  dysmenorrhoea.  But  this  probability  does  not  detract  from  the 
expediency  of  examining.  On  doing  this  we  may  be  able  to  exclude 
uterine  causes.  This  is  one  step.  The  next  is  to  obtain  evidence  of 
abnormality  outside  the  uterus.  If  we  find  fulness  of  the  vaginal  roof 
on  one  side  of  the  uterine  neck,  the  os  uteri  pushed  over  to  the  opposite 
side,  if  we  can,  by  finger  in  rectum,  and  hand  depressing  the  abdominal 
wall  above  the  pubes,  define  a  swelling  between  them,  the  presumption 
rises  that  there  is  extra-uterine  pregnancy.  Tubal  gestation  is  dis- 
tinguished from  encysted  abscess  of  the  broad  ligament  or  pelvic  peri- 
toneum by  its  smoothness,  uniformly  round  or  oval  form,  and  by  its 
mobility.  The  long  axis  of  the  oval  tumor  is  parallel  with  Poupart's 
ligament.  The  presumption  of  tubal  gestation  is  strengthened  in  pro- 
portion as  we  increase  the  evidence  of  ]3regnancy.  Thus  Huguier  says, 
the  violaceous  coloration  of  the  vagina  has  always  been  to  him  an  in- 
dication of  pregnancy,  uterine  or  extra-uterine.  Vaginal  pulsation 
may  be  felt.  Evory  Kennedy  in  one  case  detected  the  placental  souffle} 
Analysis  of  numerous  cases  proves  one  thing,  namely,  that  in  many, 
•  perhaps  in  most,  distinct  symptoms  which  may  be  regarded  as  pre- 
monitory, do  occur  before  the  final  catastrophe.  The  pain,  Goupil 
says,  is  constant.  It  is  due,  no  doubt,  to  the  stretching  of  the  tube 
chiefly,  and  in  part  to  the  pressure  of  the  enlarging  sac  upon  neighbor- 
ing structures.  Kennedy's  cases,  my  own,^  and  many  others,  show 
that  pain  occurs  early  and  continues. 

The  hemorrhage  is  not  less  constant.  I  have  several  times  pointed 
this  out  in  discussions  at  the  Obstetrical  Society.  Goupil  says,  metror- 
rhagia is  an  almost  constant  phenomenon.  _  Lesouef,  in  the  most  valu- 
able monograph  on  extra-uterine  gestation  with  which  I  am  acquainted, 
declares  that  hemorrhage  is  the  initial  fact  of  the  fatal  accidents,  and 
that  when  the  fcetal  sac  bursts,  blood  had  already  for  a  long  time  been 
poured  into  it,  distending  its  walls.  Lesouef  does  not  insist  clearly 
upon  the  escape  of  blood  externally  in  the  form  of  metrorrhagia.  But 
I  believe  this  phenomenon  is  so  frequent  that  it  may  be  regarded  as  in- 
dicative of  what  is  going  on  in  the  sac.  The  blood  which  flows  by  the 
vulva  is  to  a  certain  extent  the  overflow.  It  no  doubt  postpones  the 
climax  in  rupture.  It  should  serve  as  a  warning  of  the  impending 
danger. 

1  See  a  most  interestiiis;  memoir  on  cases  of  extra-uterine  fcetation  detected  at  an 
earl_y  stae:e. — British  Medical  Journal,  ]8G9. 

*  See  St.  Thomas's  Hospital  Keports,  vol.  i,  1871. 


TUBAl.    GESTATION.  365 

A  point  deserving  of  the  most  earnest  attention  is  that  in  many  cases 
the  fatal  catastrophe  does  not  come  in  one  single  stroke.  One  or  more 
minor  attacks,  evidently  marked  by  rnpture  and  effusion  of  blood,  occur 
several  days  before  the  final  blow  is  dealt.  The  symptoms  of  these 
preliminary  strokes  are  those  of  hsematocele.  The  first  rupture  is  prob- 
ably small,  the  ovum  perhaps  remains  entire.  If  we  could  seize  this 
moment  to  puncture  the  sac  we  might  avert  the  fatal  rupture.' 

The  physical  signs  taken  alone  might  not  enable  us  to  distinguish  an 
early  tubal  gestation  from  a  small  ovarian  cyst  or  a  tubal  dropsy. 
But  add  to  these  physical  signs,  so  similar  in  both  cases,  the  history 
and  signs  of  pregnancy,  the  pain  and  the  hemorrhage,  and  we  get  an 
accumulation  of  evidence  which  in  some  cases  at  least  amounts  to  a 
very  high  degree  of  probability  in  favor  of  tubal  gestation. 

Three  conditions  there  are  which  are  most  likely  to  be  a  source  of 
difficulty.  Retroversion  of  the  gravid  womb  ;  a  small  ovarian  cyst ; 
retro-uterine  hematocele.  The  first  and  third  of  these  conditions  will 
commonly  cause  retention  of  urine,  an  accident  which  seems  compara- 
tively rare  in  tubal  gestation.  In  the  first,  almost  constantly  there  is 
a  history  of  pregnancy,  and  the  characteristic  signs  of  it ;  in  the  third 
also  there  may  be  a  history  of  pregnancy.  Retroversion  may  be  dis- 
tinguished by  tracing  the  firm  rounded  body  of  the  uterus  by  vaginal 
and  rectal  touch  and  by  its  other  characteristic  signs.^  Retro-uterine 
hsematocele  may  be  the  result  of  abortion.  It  will,  like  tubal  gestation, 
be  attended  by  external  hemorrhages.  But  the  mass  of  blood  behind 
the  uterus  will  have  followed  on  severe  symptoms  suddenly  produced, 
and  the  uterus  will  present  a  degree  of  development  much  less  than 
that  commonly  observed  in  tubal  pregnancy.  A  small  ovarian  cyst 
may  also  cause  retention  of  urine,  but  it  does  not,  or  at  least  veiy  rarely, 
cause  suppresssion  of  menstruation.  We  may  always  negative  preg- 
nancy. 

Lesouef  cites  a  case  in  his  Memoir  (No.  vi)  of  an  extra-uterine  ges- 
tation mistaken  for  a  retroversion  of  the  womb  at  the  fourth  month. 
Puncture  was  made,  and  attempts  at  reduction.  Two  days  later  the 
foetus  passed  by  the  rectum.  There  had  been  almost  complete  sup- 
pression of  urine,  and  stoppage  of  fseces.  The  case  was  seen  by  Du- 
puytren,  Antoine  Dubois,  Lisfranc,  and  Maygrier.  I  have  also  seen 
a  case  of  gestation  in  Douglas's  pouch  which  gave  rise  to  the  same 
symptoms  and  erroneous  diagnosis. 

Fig.  82  is  a  good  illustration  of  a  tubal  gestation,  the  cyst  bursting 
at  about  the  third  month.  The  uterine  decidua  is  dissected  up,  and  is 
remarkably  developed. 

Causes  of  Tubal  Gestation. — These  are  interesting,  as  illustrative  of 
the  morbid  conditions  to  which  the  Fallopian  tube  is  liable. 

It  is  remarkable  that,  in  a  considerable  majority  of  cases,  it  is  the 
left  tube  which  is  the  seat  of  gestation  (Campbell,  Hecker).  This  may 
possibly  be  explained  by  the  fact  that  the  left  tube  is  more  liable  to 

1  See  case  No.  6,' in  the  Author's  Memoir  on  "Pelvic  Hsematocele." — St.  Tho- 
mas's Hospital  Keports,  1871. 

2  See  my  Lectures  on  "  Obstetric  Operations,"  2d  edition. 


366 


EXTRA-UTEEINE    GESTATION. 


displacement  and  compression  by  the  sigmoid  flexure,  which  lies  in 
close  relation  to  it,  and  is  often  disturbed  by  feculent  accumulations. 

The  essential  condition  of  tubal  gestation  is  obviously  arrest  of  the 
impregnated  ovum  in  the  tube.     We  have,  therefore,  to  consider  what 


Fig.  82. 


(St  Thomas's  Musi  urn,  H.  H.  19,  nat.  size.) 

Gestation  in  the  left  Fallopian  tube.    The  sac  ruptured ;  the  embryo  suspended  by  its  cord  ;  the 

uterine  mucous  membrane  developed  to  a  thick  decidua. 

are  the  conditions  which  may  lead  to  this  arrest  ?  Naturally  we  look 
to  some  mechanical  obstruction,  and  in  some  cases  this  is  found. 
Amongst  these  are — 

1.  Inflammatory  Adhesions. — Hecker^  believes  this  to  be  a  common 
cause.  He  supports  this  opinion  by  eight  dissections,  showing  ad- 
hesions impeding  the  free  course  and  connection  of  the  tubes  with  the 
ovaries ;  by  the  fact  of  the  frequent  sterility  antecedent  to  tubal  ges- 
tation ;  by  the  well-known  sterility  of  prostitutes  which  follows  upon 
colic — the  colicu  scorforum.  It  has  been  remarked,  tliat  in  many  in- 
stances the  subjects  of  tubal  gestation  had,  up  to  the  time  of  such  ges- 
tation, been  sterile.     There  is  sufficient  reason  to  admit   this  as  a 


'  Monatsschrift  fiir  Geburtskunde,  1859. 


CAUSES.  367 

frequent  cause,  but  many  cases  are  known  in  which  the  course  of  tlie 
tubes  appeared  to  be  free ;  and  in  some  cases,  in  which  adhesions  have 
been  found,  these  Avere  probably  not  antecedent  to,  but  the  consequence 
of,  the  tubal  gestation. 

2.  Obstruction  of  the  Ostium  Uterinum  by  Polypi. — Breslau^  relates 
two  cases  in  which  polypi  were  found  at  the  uterine  end  of  the  tube. 
In  one,  that  of  a  woman  aged  thirty,  who  died  of  abdominal  hemor- 
rhage six  months  after  marriage,  a  tubal  cyst,  containing  chorion  and 
blood,  occupied  the  left  tube.  The  cyst  was  close  to  the  uterine  mouth 
of  the  tube.  Inside  the  uterus,  close  to  the  mouth  of  the  tube,  was  a 
mucous  polypus,  not  quite  obstructing  the  passage  of  a  small  sound. 

This  position  of  polypus  is  not  very  uncommon.  I  dissected  a  uterus 
in  which  a  polypus  the  size  of  a  filbert  was  attached  to  the  mouth  of 
each  tube  and  occluded  it. 

Fibrous  tumors  in  the  uterus  have  been  found  in  several  cases.  A 
very  interesting  one  is  related^  by  Dr.  Magrath,  of  Jamaica.  In  Uni- 
versity College  Museum  is  a  specimen  (No.  4275)  of  tubal  gestation, 
the  sac  having  burst  at  the  fifth  month.  The  uterus  contained  several 
large  fibroids.  These  tumors  so  distort  the  form  and  relations  of  the 
uterus,  that  obstruction  to  the  passage  of  the  ovum  may  readily  occur. 
Extra-uterine  gestation,  then,  may  be  looked  upon  as  one  of  the  penal- 
ties a  woman  having  fibroid  tumors  in  tne  uterus  may  incur  if  she 
marries. 

It  has  struck  me  as  remarkable,  how  often,  in  tubal  gestation,  twins 
have  been  found.  May  it  not  be  that  the  two  ova  may  obstruct  each 
other  in  their  passage  along  the  tube  ? 

3.  Another  fact  deserves  notice.  In  the  great  majority  of  cases  of 
extra-uterine  gestation,  the  subjects  have  been  w^omen  exposed  to  hard 
work.  In  many  cases  the  women  themselves  have  assigned  this  as  the 
cause  of  their  misfortune.  It  is  quite  possible  that  great  bodily  exer- 
tion during  the  first  days  after  conception,  may  so  alter  the  relative 
position  of  the  ovaries,  tubes,  and  uterus,  as  to  impede  the  due  transit 
of  the  ovum ;  or  great  congestion  of  the  organs  may  be  induced,  caus- 
ing tumefaction  of  the  mucous  membrane. 

4.  Oldham  was,  I  believe,  the  first  to  observe  this  very  remarkable 
fact,  that  occasionally  the  corpus  luteum  was  found  in  the  opposite 
ovary  to  the  tube  in  which  the  ovum  was  developed.  How  could  this 
contradiction  be  explained  ?  The  ovum  must  have  travelled  by  an 
unusual  route.  The  problem  has  given  rise  to  the  theory  of  the  trans- 
migration of  the  ovum.  This  theory  offers  two  routes  which  the  ovum 
may  take. 

1st.  The  Extra-uterine  Transmigration. — Oldham  and  Wharton  Jones 
found,  in  a  left  interstitial  gestation,  the  corpus  luteum  in  the  right 
ovary ;  the  right  pavilion  was  obliterated,  and  both  observers  believed 
that  this  obliteration  was  of  old  date,  so  that  the  ovum  could  not  have 
passed  by  it.  The  uterine  portion  of  the  left  tube  was  drawn  towards 
the  posterior  wall  of  the  uterus  by  false  ligaments,  which  were  also 

1  Monatsschrift  fiir  Geburtskunde,  1863.  *  Obstetrical  Transactions. 


368 


EXTRA-UTERINE    GESTATION. 


found  at  the  far  extremity  of  this  pavilion,  which  was  thus  brought 
into  contact  with  the  right  ovary,  and  had  directly  received  the  ovum 
from  it, 

Rokitansky  found  in  a  woman  who  had  died  after  a  uterine  preg- 
nancy, the  yellow  body  on  the  left ;  the  abdominal  portion  of  the  left 
tube,  for  a  space  of  two  inches,  was  thinned,  impervious,  its  pavilion 
adherent  to  the  sigmoid  flexure  above  the  brim  of  the  pelvis ;  the 
right  tube  was  mobile.  He  believes  that  the  conception  took  place 
after  these  adhesions  had  been  formed,  and  that  the  ovum  had  passed 
into  the  uterus  from  the  left  ovary  by  the  right  tube. 

In  these  two  cases,  then,  it  seems  difficult  to  avoid  the  conclusion 
that  the  fertile  ovum  travelled  from  its  ovary  to  the  opposite  tube. 
Klob  and  Kussmaul  showed,  what  any  one  may  see  on  the  dead  body, 
how  easily  the  fimbriated  extremity  of  the  right  tube  may  be  applied 
to  the  surface  of  the  left  ovary,  and  vice  versa.  But  Kussmaul  does 
not  regard  this  contact  as  necessary.  Hq  invokes  observations  made 
on  amphibia,  in  which  it  is  certain  that  actual  contact  between  tube 
and  ovary  does  not  take  place.  And  Miiller  and  Becker  have  de- 
scribed a  vibratile  current  running  from  the  ovary  to  the  tube,  which 
may  sweep  the  ovum  over  the  intermediate  space  into  the  tubes. 
Maurer's  case  is  another  illustration  of  the  extra-uterine  transmigration. 

A  case  that  seems  decisive  as  to  the  possibility  of  the  extra-uterine 


Gestation  in  a  rudimentary  horn  of  the  uterus — front  view.— (After  Luschka.) 
A,  the  developed  horn  of  the  uterus  (right) ;  b,  the  rudimentarj'  horn  with  a  rent,  through  which 
the  fcetiis  has  escaped  (left).     1,  the  Fallopian  tube  (right);  2,  the  Fallopian  tube  (left);  4,  5,  right 
ovary  and  corpus  luteum  ;  6,  round  ligament. 


transmigration,  is  related  by  Luschka.^  A  woman  died  under  the 
usual  signs  of  rupture  of  a  fruit-sac  when  about  ten  weeks  pregnant. 
It  was  found  that  the  fruit-sac  was  in  the  rudimentary  horn  of  a  one- 
horned  uterus,  Avhilst  the  corpus  luteum  was  in  the  opposite  ovary. 

1  Schwangorschaft  i-  d,  rechten  riidimentiiren  Horne,  &c.,  M.  f.  G.,  18(53. 


MIGRATION    OF    OVUM.  369 

ISTo  communication  could  be  found  between  the  sac  of  the  rudimentary 
horn  and  the  cavity  of  the  developed  half  of  the  uterus,  so  that  intra- 
uterine migration  is  necessarily  excluded  in  this  case.  It  is  convenient 
to. give  Luschka's  figure  here;  the  reader  can  refer  to  it  when  studying 
the  subject  of  pregnancy  in  a  rudimentary  horn  further  on. 

In  several  other  cases  in  which  the  corpus  luteum  was  found  in  the 
ovary  of  the  same  side  as  the  fruit-sac,  the  rudimentary  horn  contain- 
ing it  had  no  communication  with  the  cavity  of  the  developed  horn. 
Here  we  may  conjecture  that  the  spermatozoa  found  their  "svay  through 
the  developed  horn  and  its  tube,  being  thus  conveyed  across  outside 
the  uterus  to  the  ovary  of  the  opposite  side ;  unless,  indeed,  we  con- 
clude that,  at  the  time  of  the  conception,  a  communication  between 
the  cavities  of  the  two  horns  did  exist,  which  became  closed  during 
gestation. 

Schultze^  relates  a  case  of  a  tubo-uterine  gestation,  carried  to  term. 
The  gestation  was  on  the  right  side,  the  corpus  luteum  on  the  left. 
The  right  tube  was  impervious  at  both  ends.  This  would  appear  a 
case  of  extra-uterine  transmigration. 

In  the  London  Hospital  Museum  (E.  h.  28)  is  a  specimen  in  point. 
It  exhibits  the  uterus  and  ovaries  of  a  woman  who  died  very  suddenly, 
and  was  suspected  to  be  poisoned.  There  is  a  tubular  conception  and 
ruptured  sac  on  the  left  side ;  the  corpus  lut'eum  is  on  the  opposite  side. 
Indeed,  cases  of  this  kind  appear  to  be  not  very  uncommon. 

2d.  The  Intra-uterine  Transmigration. — Tyler  Smith,  I  believe  it 
was,  who  started  the  hypothesis  that  the  ovum  might  be  received  into 
its  appropriate  tube,  enter  the  uterus,  cross  the  cavity,  and  penetrate 
the  opposite  tube,  where  it  might  become  developed.  There  are  facts 
which  support  this  idea.  That  the  ovum  does  wander  in  the  uterine 
cavity  is  proved  by  the  cases  of  placenta  prsevia,  where  the  ovum  gets 
to  the  cervical  zone,  and  also  in  some  rare  cases  even  into  the  cervical 
cavity,  constituting  cervical  gestation.  Klob,^  however,  disputes  the 
possibility  of  intra-uterine  migration. 

But  it  must  be  remembered  that  in  a  considerable  proportion  of  cases 
of  tubal  gestation,  the  corpus  luteum  is  on  the  same  side  as  the  embry- 
onic sac,  and  that  no  obstruction  by  adhesions  or  tumors  can  be  found. 
Here  we  may  suppose  that  a  temporary  flexion  of  the  tube  may  pre- 
sent a  spur  or  valve  at  some  point  on  the  uterine  side  of  the  ovum  and 
block  its  onward  course. 

Coste  conjectured  that  a  shock — moral  or  physical — occurring  within 
some  days  after  coitus,  might  cause  extra-uterine  gestation. 

I  will  now  describe  what  I  believe  is  the  exact  order  and  course  of 
events  in  the  greater  number  of  cases  of  tubal  gestation.  The  ovum  is 
impregnated  either  in  the  ovary,  as  Coste  thought  probable,  or  after  its 
reception  in  the  tube.  Arrested  there,  it  grows,  developing  its  chorion 
into  placenta,  and  distending  the  walls  of  the  tube  into  a  sac,  until  the 
time  arrives — seldom  postponed  beyond  three  months — when  the  growth 
of  the  ovum  outstrips  the  growth  and  stretching  of  the  tube  which  con- 

'  Wurzbur2;er  Med.  Zeitschrift,  Band  iv. 

2  Wochenblatt  d.  Ztschr.  d.  k.  k.,  Ges.  d.  A.  in  Wien,  1861. 

24 


370  EXTEA-UTEEINE    GESTATION. 

tains  it.  The  great  majority  of  cases  terminate  in  rupture  within  eight 
weeks  (Hecker).  Mr.  George  Roper  observed  that  the  rupture  occurred 
at  a  menstrual  period.  This  increases  the  analogy  I  have  pointed  out 
between  tubal  gestation  and  placenta  prsevia.  The  tube  does  not  burst 
at  once ;  if  it  did  there  would  be  no  premonitory  hemorrhage.  This 
hemorrhage  I  account  for  on  the  same  hypothesis  as  that  by  which  it 
seems  to  me  certain  that  the  hemorrhage  in  placenta  preevia  is  explained. 
In  both  cases  the  gestation  is  ectopic,  that  is,  proceeding  in  an  abnormal 
locality  which  is  unfit  for  the  office  imposed  upon  it.  The  Fallopian 
tube,  like  the  lower  segment  of  the  uterine  cavity,  has  only  a  limited 
capacity  of  growth.  This  is  soon  overtaken  by  the  growing  ovum, 
which,  not  finding  the  room  it  requires,  excites  spasmodic  contractions 
of  the  sac.  Hence  partial  detachment  of  the  ovum  is  caused,  and  some 
hemorrhage  ensues.  In  the  case  of  tubal  gestation,  partial  detachment 
is  very  easy,  owing  to  the  scanty  development  of  decidua.  This  hem- 
orrhage, in  both  cases  of  placenta  prsevia  and  of  tubal  gestation,  may 
escape  externally.  In  the  first  case,  the  os  uteri  offers  a  ready  exit ;  in 
the  second  case,  the  exit  is  not  so  easy,  and  the  sac  is  comparatively 
feeble.  Hence  a  large  proportion  of  the  blood  poured  out  by  the 
severance  of  relation  between  placenta  and  sac  is  retained  in  the  sac. 
The  distension  becomes  extreme.  Renewed  spasmodic  action  of  the 
muscular  Avail  is  excited,  and  the  sac  bursts.  The  ovum  itself  does 
not  always  burst,  and,  probably,  rarely  does  until  the  sac  has  done  so. 
The  accumulated  blood  in  the  tube,  together  with  fresh  blood  pro- 
ceeding from  the  torn  vessels  of  the  tube,  is  now  poured  into  the  ab- 
dominal cavity,  causing  the  shock  and  other  phenomena  that  mark 
the  climax. 

The  influence  of  extra-uterine  gestation  upon  the  uterus  is  an  im- 
portant point  to  consider.  The  remark  of  Velpeau  that  the  sexual 
organs  show  little  departure  from  their  ordinary  state  when  the  foetal 
sac  is  not  in  the  tube,  and  do  not  contract  adhesions  with  the  uterus, 
is  generally  true.  But  in  every  museum  which  can  show  specimens 
of  tubal  gestation  will  be  found  ample  evidence  of  enlargement  of 
the  uterus,  and  of  the  development  of  the  mucous  membrane  into 
decidua;  and  this  is  entirely  in  accordance  with  physiological  knowl- 
edge. The  uterine  mucous  membrane,  as  we  have  already  seen,  swells 
and  undergoes  development  into  decidua  under  the  mere  stimulus  of 
ovulation.  This  development  is  a  necessary  preparation  for  the  recep- 
tion of  the  ovum.  It  is  not  a  necessary  condition  for  its  formation 
that  the  ovum  should  reach  the  uterus.  But  why,  it  may  be  asked, 
is  the  decidua  so  constantly  found  in  tubal  gestation  preserved  so 
long  as  three  months  when  it  is  not  wanted  ?  And  why  is  it  not  ob- 
served in  many  cases  of  abdominal  gestation?  The  explanation  is 
found  in  the  remark,  before-cited,  of  Velpeau.  In  tubal  gestation,  the 
engorgement  of  the  uterus  and  the  physiological  stimulus  are  main- 
tained by  the  proximity  of  the  foetal  sac;  whilst  in  abdominal  gesta- 
tion the  developmental  stimulus  and  the  vascular  system  supplying  the 
sac  are  remote  from  the  uterus.  Still,  in  many  cases  where  the  sac 
adheres  to  the  uterus  and  ])resses  upon  it,  this  organ  is  greatly  enlarged, 
and  its  mucous  membrane  is  highly  developed.     As   to  the  formation 


TREATMENT.  371 

of  decidua  in  the  tube  itself,  it  might  be,  a  'priori,  supposed  that  the 
tube  having  a  mucous  membrane,  and  the  physiological  necessity  for  a 
decidua  being  present,  a  decidua  would  be  formed.  But  Oldham,^  Ki- 
wisch,  and  Virchow  have  shown  that  it  is  not  so.  The  mucous  mem- 
brane in  the  tube  is  deficient  in  the  utricular  glands  which  the  uterine 
membrane  possesses.  A  careful  examination  of  specimens  confirms 
Virchow's  observation.  The  chorion  villi  seem  to  be  implanted  di- 
rectly upon  the  mucous  membrane.  The  condition  of  the  mucous 
membrane  of  the  tube  has  been  investigated  by  Poppel,^  who  says  that 
even  if  a  decidua  vera  be  formed,  there  is  certainly  no  serotina.  Hen- 
nig  has  also  studied  the  question.^  He  shows  greater  similarity  be- 
tween the  behavior  of  the  uterine  and  tubal  mucous  membranes  under 
gestation  than  was  before  suspected.  If,  he  adds,  there  be  no  serotina 
in  tubal  gestation,  the  placenta  is  developed  on  a  different  plan  to  that 
of  the  normal  uterine  placenta;  it  is  developed  according  to  the  plan 
which  governs  the  normal  gestation  in  rabbits,  cats,  and  dogs. 

This  slender  attachment  may  serve  to  explain  the  facility  with  which 
separation  and  hemorrhage  take  place.  Also,  in  abdominal  gestation, 
there  is  no  true  decidua.  The  placenta  is  attached  directly  to  the  sur- 
face of  the  uterus  or  of  some  abdominal  organ. 

The  body  of  the  uterus  is  commonly  enlarged  when  the  sac  is  in  any 
way  attached  to  it. 

The  Treatment. — A  careful  study  of  the  history,  course,  and  premoni- 
tory symptoms  of  tubal  gestation,  will  encourage  the  hope  that  we  may 
in  some  cases  at  least  avert  the  ultimate  catastrophe.  In  the  early 
stages,  before  hemorrhage  has  occurred,  if  pain  and  local  distress  have 
led  to  an  examination,  and  the  detection  of  fulness  in  the  vaginal  roof 
a  little  on  one  side  of  the  uterus,  which  we  conclude  to  be,  on  grounds, 
described  under  "Diagnosis,"  due  to  a  tubal  cyst,  we  have,  I  think,  a 
sufficient  indication  to  act  decisively.  Lesouef  has  rightly  said  that 
every  woman  who  has  become  the  subject  of  an  extra-uterine  gestation, 
is  doomed  to  more  or  less  speedy  death.  This  is  eminently  true  of 
tubal  gestation.  Error  of  diagnosis  is  the  only  justifiable  ground  for 
hesitation.  And  for  what  is  a  tubal  gestation  likely  to  be  mistaken  ? 
Most  likely  for  a  small  ovarian  cyst.  Now  here  is  a  case  of  which  we 
have  many  analogous  examples  in  medicine.  Whichever  view  be  right, 
the  same  treatment  applies ;  and  hence  the  error  entails  no  harm.  The 
indication  in  both  cases  is  to  arrest  the  growth  of  the  cyst. 

This  can  be  done  by  tapping  it ;  and  tapping  through  the  vagina  or 
rectum  by  means  of  the  fine  aspirator-trocar  is  infinitely  less  dangerous 
than  letting  the  disease  go  on  to  its  ordinary  and  almost  inevitable  ter- 
mination. 

In  the  case  of  tubal  gestation,  there  being  no  available  outlet,  we  are 
precluded  from  the  induction  of  labor.  But  the  embryo  may  be  killed, 
and  thus  the  development  of  the  sac  cut  short.  Electricity. — Dr.  Bac- 
chetti*  described  a  case  in  which  two  needles  were  passed  into  the  tubal 

1  Guy's  Hospital  Report,  1843. 

2  Monatsschrift  fiir  Gerburtskunde,  vol.  xxxi. 

3  Ibid.,  18«9. 

''  Gazetta  medica  toscana,  1853. 


372  EXTRA-UTEEINE    GESTATION. 

sac,  and  then  a  current  of  electricity  was  passed  through  by  means  of  a 
Bunsen's  pile.  Two  shocks  were  administered.  The  growth  of  the 
tumor  was  arrested,  and  the  patient  did  well.  Of  course  it  may  be 
doubted  whether  there  was  really  a  tubal  gestation  ;  but  in  any  case  it 
is  proved  that  the  puncture  may  be  safely  made.  Duchenne,  consulted 
by  Lesouef,  suggested  resort  to  electricity  in  the  state  of  tension  by  a 
Leyden  jar.  He  ascertained  that  the  discharge  of  a  Leyden  jar  pro- 
duced a  profound  local  stupor,  and  that  for  a  certain  time  the  capillary 
circulation  and  calorification  were  diminished  in  the  tissues  operated 
on.  The  method  he  recommends  is,  to  cover  the  stem  of  the  exciters 
with  a  thick  coating  of  wax,  leaving  only  the  terminal  ball  bare.  One 
excitor  is  then  passed  into  the  rectum,  endeavoring  to  place  it  in  contact 
with  the  postero-superior  side  of  the  tumor.  The  lumbo-sacral  plexus 
must  be  avoided,  else  the  mother  will  receive  the  shock.  The  second 
excitor  is  passed  into  the  vagina,  and  the  ball  is  applied  to  the  antero- 
inferior wall  of  the  cyst.  Thus  arranged,  the  rectal  excitor  is  put  in 
communication  with  the  external  armature  by  a  chain  suitably  isolated. 
It  then  only  remains  to  bring  the  internal  armature  in  contact  with 
the  vaginal  stem  by  a  glass  stem  excitor.  The  electricity  will  recom- 
pose  itself  across  the  foetal  cyst,  and  it  seems  inevitable  that  the  stream 
must  traverse  the  embryo. 

This  mode  of  applying  electricity  seems  preferable  to  that  of  Bac- 
chetti,  inasmuch  as  no  wound  is  inflicted.  Indeed,  Bacchetti's  plan 
may  be  excluded  on  the  ground  that,  having  made  the  puncture,  elec- 
tricity is  superfluous. 

Drawing  off  the  Liquor  Amnii. — The  sac  deprived  of  this  element  will 
naturally  collapse,  the  ovum  will  in  all  probability  perish,  and  atrophy 
by  absorption  ensuing,  cure  will  be  attained.  If  the  aspirator-trocar 
be  used,  the  liquor  amnii  can  be  easily  drained  off. 

It  had  already  been  proposed  by  Basedow  to  puncture  the  cyst 
through  the  vagina,  to  drain  off  the  liquor  amnii,  and  thus  to  kill  the 
embryo.  This  method  was  advocated  by  Kiwisch,^  who  recommended 
to  pass  a  small  trocar  into  the  cyst  by  the  vagina. 

Professor  Friedreich^  of  Heidelberg  relates  a  most  interesting  case 
in  which,  having  detected  a  tubal  cyst  which  gave  rise  to  great  pain, 
and  was  increasing  so  rapidly  that  bursting  was  apprehended,  he  made 
three  injections  of  a  solution  of  morphia  into  the  cyst.  He  based  this 
proceeding  on  the  known  susceptibility  of  the  infant  organism  to  opium. 
Complete  success  followed.  The  tumor  shrank  to  a  small  hard  knot, 
and  all  the  distressing  symptoms  vanished.  It  is  not,  however,  clear 
whether  the  same  result  might  not  have  been  obtained  by  the  punc- 
tures alone,  the  morphia  injections  being  superfluous.  Some  degree  of 
inflammation  is  pretty  sure  to  follow  puncture,  and  this,  no  doubt,  will 
insure  the  death  of  the  foetus,  and  arrest  the  growth  of  the  cyst. 

Dr.  Greenhalgh^  describes  a  case  in  which  he  arrested  the  develop- 
ment of  a  tubal  gestation  by  puncture  through  the  vagina. 

Professor  E,  Martin^  relates  an  interestmg  case  in  which  he  pursued 

1  Klinische  Vortra<;e,  Prae;.,  1849.     11  Abtheilung.  S.  275. 

2  Virchow's  Archiv.,  29,  1863. 

3  Lancet,  1807.  *  Monatsschrift  fiir  Geburtskunde,  1868. 


TREATMENT.  373 

the  same  method.  The  subject  was  about  three  months  pregnant  when 
she  had  symptoms  of  pelvic  injury,  with  hemorrhage  externally,  sug- 
gesting rupture  of  a  gestation-sac.  A  small  spindle-shaped  tumor  was 
felt  above  the  left  horizontal  pubic  bone.  The  body  of  the  uterus  was 
pushed  over  to  the  right  side,  the  os  uteri  to  the  right.  In  the  left 
side  of  the  roof  of  the  vagina  the  same  spindle-shaped  tumor  was  felt. 
Examination  at  intervals  had  shown  that  this  tumor  increased  rapidly. 
Martin  punctured  it  through  the  vagina  with  an  exploratory  trocar. 
A  few  drops  of  bloody  serum  escaped.  Some  constitutional  reaction 
ensued  ;  the  woman  quite  recovered.  The  tumor  disappeared,  and  the 
uterus  regained  its  normal  position. 

The  late  Professor  Simpson^  related  a  case  in  which  a  patient  who 
had  suffered  rupture  of  an  extra-uterine  cyst  was  punctured  by  the 
vagina  "  to  evacuate  the  liquor  amnii,  to  effect  death  of  foetus  and  sub- 
sequent decomposition  and  expulsion."  Death  occurred  through  peri- 
tonitis. The  sac  was  formed  by  the  enlarged  uterus,  broad  ligaments, 
pelvic  walls,  and  sigmoid  flexure.  The  foetus  was  of  six  months'  de- 
velopment. In  such  a  case  gastrotomy  would  be  preferable.  Mere 
puncture  could  do  no  good. 

Dr.  Rupin'^  relates  a  case  of  twin-pregnancy  outside  the  uterus.  A 
cyst  was  felt  projecting  in  the  roof  of  the  vagina,  which  was  punctured, 
and  liquor  amnii  drained  off;  a  foetus  of  four  months  escaped.  The 
patient  died  of  violent  hemorrhage  three  days  afterwards.  On  autopsy, 
a  second  foetus  was  found  in  a  sac  deep  in  the  pelvis.  Probably  this 
was  not  a  tubal  gestation. 

Can  we  an'est  embryonic  growth  by  means  of  agents  introduced  into 
the  blood  f 

M.  Delfrayssc'^  relates  instances  of  retardation  of  the  growth  of  the 
foetus  by  continued  doses  of  iodine.  Many  attempts  in  ancient  and 
modern  times  have  been  made  by  starvation  and  drugs  to  accomplish 
this  object.  I  do  not  insist  upon  them,  because  I  have  no  faith  in  their 
efficacy.  It  is  possible,  however,  that  strychnine  carried  so  far  as  to  pro- 
duce minor  toxical  symptoms  in  the  mother,  might  destroy  the  embryo. 
Syphilis  has  more  power  than  almost  any  poison  we  are  acquainted  with 
over  the  foetus,  almost  always  either  killing  it,  or  impeding  its  develop- 
ment. Might  it  not  be  justifiable  in  such  a  case  as  we  are  discussing 
to  practice  syphilization  ?  I  do  not  dwell  upon  this  repulsive  method, 
because  I  believe  simple  puncture  of  the  sac  is  the  right  course  to  adopt. 

If  the  opportunity  of  treatment  during  development  has  been  passed 
by,  and  rupture  has  taken  place,  what  is  the  course  to  be  adopted  ? 

The  question  has  often  been  discussed,  whether  it  is  not  advisable  to 
perform  gastrotomy  with  a  view  to  removing  the  embryo  and  effused 
blood,  and  checking  further  bleeding  by  tying  the  Fallopian  tube  on 
the  proximal  side  of  the  sac,  and  cutting  away  the  sac  ?  I  can  liardly 
imagine  that  this  idea  will  ever  be  successfully  carried  out  in  these  cases 
of  early  tubal  rupture.     In  the  first  place,  the  greater  number  of  sub- 

1  Edinburgh  Medical  Journal,  1864. 

2  Gazette  de  Hopitaux,  1860. 

^  Comptes  rendus  de  I'Academie  des  Sciences,  1850. 


374  EXTRA-UTERINE    GESTATION. 

jeets  die  within  a  few  hours  from  the  primary  shock  of  the  injury  and 
hemorrhage.  Removal  of  the  blood  by  gastrotomy  must  add  to  this 
shock,  and  cannot  restore  the  lost  blood.  And,  secondly,  to  discover 
the  source  of  the  bleeding  and  to  remove  the  blood  is  by  no  means 
easy.  I  have  found  considerable  difficulty  in  tracing  the  parts  with 
all  the  advantages  incident  to  a  post-mortem  examination.  Thirdly, 
if  we  could  tie  the  Fallopian  tube,  and  amputate  the  sac,  the  pain 
caused  by  the  ligature  would  probably  be  so  intense  as  by  itself  to 
exhaust  the  vital  power.  I  fear  the  actual  state  of  science  has  no  resource 
beyond  the  old  one  of  rallying  the  patient  from  collapse  by  cautious  ad- 
ministration of  stimulants,  of  ]jrocuring  rest  by  opium,  and  by  control- 
ling inflammation,  if  the  patient  survives  until  this  conservative  pro- 
cess sets  in.  If  this  fortunate  event  should  be  reached,  the  case  may 
resolve  itself  into  one  of  encysted  pelvic  hsematocele,  and  must  be  treated 
on  the  principles  laid  down  for  that  condition. 

But  this  issue  by  cataclysmic  rupture  is  not  invariable.  I  agree 
with  Lesouef 's  observation  that  extra-uterine  gestation  is  a  far  more 
frequent  accident  than  is  supposed,  and  that  if  it  be  so  rarely  observed, 
it  is  because  the  embryo  in  the  greatest  number  of  cases  is  destroyed 
in  the  first  days  of  its  development.  No  appreciable  symptom  then 
is  manifested,  or  if  the  physician  is  called  in,  it  is  impossible  for  him 
to  refer  what  he  sees  to  its  true  cause.  When  a  tubal,  ovarian,  or  ab- 
dominal gestation  is  brought  to  an  end  in  the  first  days,  the  hemor- 
rhage may  not  be  fatal,  and  the  rational  signs  of  gestation  not  having 
yet  appeared,  the  source  of  the  resulting  hsematocele  escapes  detection. 
In  these  cases  the  hemorrhage  may  escaj)e  from  the  surface  of  the  tube 
or  from  its  open  end.  There  is  not  necessarily  rupture  of  the  tube ; 
but  the  embryo  perishes,  and  a  hsematocele  is  formed.  I  have  related 
cases,  upon  my  interpretation  of  which  of  course  it  is  easy  for  criticism 
to  cast  a  doubt,  l)ut  which  I  nevertheless  believe  to  be  of  this  nature. 
In  yet  another  order  of  cases,  rupture  of  the  tubal  sac  takes  place 
early,  the  hemorrhage  is  not  fatal,  and  the  impregnated  ovum  escaping 
into"  the  abdominal  cavity  may  graft  itself  upon  the  peritoneum,  when 
a  sac  will  be  formed  by  false  membranes. 

Lesouef,  (quoting  Bernutz,  says :  "  If  the  rupture  of  the  tubal  sac 
takes  place  on  a  level  with  the  attached  border  of  the  tube,  the  blood 
will  find  its  way  into  the  cellular  tissue  of  the  broad  ligament,  and 
thus  find  difficulty  in  effusion,  whilst  the  ovum  will  insiimate  itself 
in  the  route  made  between  the  folds  of  the  broad  ligament,  and  become 
developed  there.  For  it  must  be  remembered  that  the  ovum  itself 
rarely  ruptures,  its  envelopes  remain  intact,  and  its  vitality  is  not 
necessarily  destroyed." 

The  tubal  gestation  may  go  on  to  term.  This  issue  is  exceedingly 
rare ;  so  rare,  that  a  case  which  Spiegelberg-  relates  he  believes  to  be 
singular.  Convulsions  came  on  in  a  woman  at  term,  with  signs  of 
labor ;  copious  albumen  Avas  found  in  the  urine.  She  died  after  three 
•days,  the  convulsions  and  albuminuria  having  ceased  on  the  death  of 
the  child.     The  cause  of  death  was  perforation  of  the  sac.     Examina- 


1  Archiv.  f.  Gvnalvologie,  1870. 


TREATMENT.  375 

tion  showed  that  the  sac  was  tubal ;  a  sound  passed  from  the  uterus 
into  it ;  muscular  fibres  were  found  over  the  surface ;  the  sac  was  in- 
closed between  the  two  layers  of  the  broad  ligament ;  the  ovary  was 
found  entire.  I  am  unwilling  to  hint  a  doubt  of  the  accuracy  of  so 
excellent  an  observer  as  Spiegelberg ;  but  it  appears  possible,  even  in 
this  case,  that  there  had  been  at  an  early  stage  rupture  of  the  tube  at 
its  lower  margin,  which  had  given  opportunity  for  the  ovum  to  extend 
its  sac  by  opening  up  a  space  between  the  folds  of  the  broad  ligament. 

The  question  of  performing  gastrotomy  to  extract  a  foetus  developed 
outside  the  uterus  will  be  more  conveniently  discussed  after  the  de- 
scription of  the  other  forms  of  extra-uterine  gestation. 

It  will  be  convenient  here  to  refer  briefly  to  the  other  forms  of  extra- 
uterine gestation.  These  are  the  ovarian,  the  tubo-ovarian,  the  abdom- 
inal, and  the  interstitial. 

Ovarian  Gestation. — The  reality  of  this  form  has  been_  doubted. 
Velpeau  and  Arthur  Farre  especially  contend  for  the  negative.  The 
reasons  adduced  are  twofold :  1st,  the  physiological  one,  which  is  based 
upon  the  assumption  that  the  ovum  must  have  escaped  from  the  ovary 
before  it  can  be  impregnated ;  2d,  the  anatomical  one.  It  is  urged 
that  there  is  no  clear  evidence  of  a  foetus  or  foetal  membranes  having 
been  discovered  in  the  ovary.  Professor  A.  Willigk^  advocates  this 
view,  and  criticizes  the  alleged  cases.  He  has  carefully  dissected  several, 
and  failed  to  find  foetus  or  membranes  in  the  ovary.  It  is  needless 
to  sav  that  the  microscope  is  necessary  to  identify  presumed  chorion 
villi."' 

On  the  other  hand,  there  are  cases  which  it  is  hypercritical  to  set 
aside  as  being  imperfectly  observed.  And  the  physiological  objection 
falls  to  the  ground  if  we"^  accept  the  conclusion  of  Bischoff  and  Coste 
that  impregnation  does  take  place  in  the  ovary.  Thus  Duverney^  re- 
lates a  case  given  by  De  Saiut-Morissey,  of  a  lady  who,  pregnant  for 
the  ninth  time,  at  three  months  fell  ill  with  collapse  from  severe  colic 
in  the  right  groin.  She  died  in  nine  or  ten  hours.  The  abdomen  was 
full  of  clots,  and  a  small  foetus  was  found  in  the  midst.  The  right 
ovary  was  torn  longitudinally,  and  in  the  half  of  the  side  not  attached 
to  the  tube  its  whole  capacity  was  filled  with  clots.  Every  one  present 
was  satisfied  that  this  was  the  spot  where  the  foetus  had  been  formed. 

Goupil  cites  a  case  from  Ucelli.  A.  Avoman  who  had  had  three  prem- 
ature labors,  was  pregnant  for  the  fourth  time.  At  the  third  month 
she  passed  a  fleshy  vesicular  mole  the  size  of  a  hen's  egg.  Pain,  vom- 
iting, syncope,  were  followed  by  death.  A  small  foetus  was  found  in 
the  right  iliac  fossa,  attached  to  the  ovary  of  the  same  side  by  its  funis. 
This  ovar}^  was  of  the  size  and  form  of  a  goose's  egg,  and  had  an 
opening  by  which  the  foetus  escaped.     The  uterus  was  enlarged. 

Dr.  P.  U.  AA^alter,^  of  Dorpat,  discussing  the  question,  relates  a  case 
minutely  dissected,  and  of  which  the  parts  are  represented  in  draw- 
ings, in  which  the  foetus  was  developed  in  the  ovary  for  some  mouths, 
when  the  cyst  burst,  and  further  development  proceeded  in  the  abdomi- 


1  Prag.  Vjhrt^^chr..  Ixviii,  ^  ii  (Euvres  Anatomiques,"  171. 

^  Monutsschrift.  fiir  Geburtskunde,  1861. 


376  EXTEA-UTEEINE    GESTATION. 

nal  cavity.  Aud  Hecker,  whose  authority  is  great,  relates^  a  case  which 
he  believed  to  have  been  one  of  ovarian  gestation.  Kiwisch,  whilst 
admitting  that  ovarian  gestation  is  not  proved  by  observation,  contends 
for  the  possibility  of  its  occurrence. 

A  case  is  related  by  Uhde^  of  a  young  woman  who  died  under  the 
usual  signs  of  "abdominal  collapse."  Blood  was  found  in  the  perito- 
neum. The  right  ovary  was  enlarged  and  emphysematous ;  at  its  lower 
and  hinder  part  was  a  sac  formed  of  chorion,  which  had  burst.  It  was 
the  size  of  a  large  plum,  and  contained  an  embryo  1'"  to  8'"  long. 
The  right  tube  was  hanging  quite  free,  its  fimbrise  loose.  The  prepara- 
tion is  preserved,  and  affords  a  good  means  of  testing  the  reality  of 
ovarian  gestation. 

It  is,  prirnd  facie,  unphilosophical  to  affirm  an  absolute  negative. 
It  is,  then,  wise  to  admit  that  ovarian  gestation  may  happen,  but  safe 
to  affirm  that  it  is  very  rare.  During  life  it  would  be  difficult,  if  not 
impossible,  to  diagnose  it  from  tubal  gestation.  If  detected  before 
rupture,  it  would  be  right  to  treat  it  by  puncture  in  the  same  way,  for 
the  histories  of  the  few  cases  narrated  show  that  the  ovarian  sac,  like 
the  tubal  one,  is  apt  to  burst  early.  Probably  a  more  frequent  issue  is 
the  merging  into  the  tubo-ovarian  or  abdominal  forms. 

The  tubo-ovarian  form  is  not  very  infrequent.  Probably  its  history 
commences  with  arrest  and  development  of  the  ovum  just  within  the 
fringes  of  the  pavilion  of  the  tube,  so  that  this  structure  supplies  part 
of  the  sac,  the  rest  being  made  up  by  adhesions  contracted  with  the 
ovary.  It  may  also  arise  from  original  tubal  gestation,  early  rupture 
of  the  tubal  sac,  and  fusion  of  this  with  the  surface  of  the  ovary  by 
adhesions.  The  occurrence  of  signs  of  pelvic  inflammation  at  some 
period  in  the  history  of  these  cases  supports  the  probability  of  this 
event.  The  tubo-ovarian  gestation,  like  the  abdominal  form,  differs 
from  the  tubal  by  the  greater  probability  of  the  gestation  going  on  to 
the  full  development  ojp  the  foetus.  What  then  happens  will  be  consid- 
ered under  "  Abdominal  Gestation." 

Abdominal  Gestation. — It  appears  to  me  doubtful  whether  abdominal 
gestation  is  ever  primary,  that  is,  whether  the  impregnated  ovum 
attaches  itself  ab  initio  to  some  part  of  the  peritoneum.  It  can  scarcely 
be  doubted  that  ova,  impregnated  or  not,  frequently  are  missed  by  the 
morsus  diaboli,  and  fall  into  the  abdominal  cavity,  there  to  perish. 
Kiwisch  and  others,  who  disl^elieve  in  ovarian  impregnation  and  ges- 
tation, insist  that  spermatozoa  also  find  their  way  into  the  peritoneum, 
and  may  there  meet  the  stray  ovum,  and  give  rise  to  primary  abdomi- 
nal gestation.  Such  a  fortuitous  concourse  of  atoms  resulting  in  gesta- 
tion must  be  very  rare,  and  rests  at  present  on  conjecture.  It  seems 
hardly  possible  for  a  floating  ovum  to  graft  itself  upon  the  smooth  free 
surface  of  the  peritoneum,  and  there  to  find  the  conditions  for  its  devel- 
opment. Probably,  then,  abdominal  gestation  is  always  secondary  upon 
tubal  or  ovarian  gestation.  After  these  latter  forms  have  proceeded  a 
little  way,  the  sac,  as  we  have  seen,  gives  way,  but  the  ovum  is  not  cast 
out  of  its  original  habitat;  it  maintains  its  vitality  by  retaining  part  of 


1  Monatsschrift  fur  Geburtskundo,  1859.  ^  ibid.,  1857. 


ABDOMINAL.  377 

its  original  attachments.  Inflammation  of  the  peritoneum  is  excited 
by  the  rupture  and  effusion  of  blood ;  neighboring  organs  get  connected 
by  adhesions  with  the  sac ;  the  embryo  and  its  envelopes  grow  into 
the  new  space ;  fresh  effusions  of  lymph  are  thrown  out  surrounding 
all;  and  thus  a  new  sac  is  formed,  in  which  it  is  difficult  to  trace  the 
original  tubal  structure.  It  is  only  when  the  opportunity  occurs  of 
dissecting  the  parts  at  an  early  stage  of  gestation,  that  we  can  expect 
to  unravel  the  structures  involved  in  the  sac.  JSTo  loug  time  elapses 
without  the  complication  of  inflammation  and  false  membranes  impli- 
cating neighboring  organs,  whilst  possibly  a  process  of  atrophy  of  the 
original  structures  forming  the  cyst  has  altogether  confounded  analy- 
sis. That  the  original  gestation  may  be  ovarian  and  not  tubal  seems 
proved  by  a  case  related  by  the  late  Dr.  Dyce,  of  Aberdeen.  A  woman 
died  after  having  carried  an  abdominal  gestation  eight  years,  and  hav- 
ing had  two  uterine  pregnancies  in  the  meanwhile.  Both  Fallopian 
tubes  icere  found  entire,  but  no  trace  of  one  ovary  could  be  detected. 

In  abdominal  gestation  the  same  course  may  be  observed  as  in  oixli- 
nary  gestation  up  to  a  certain  point.  But  intercurrent  attacks  of  pain, 
the  expression  probably  of  attacks  of  peritonitis,  are  apt  to  occur.  The 
cyst  may  burst,  as  in  a  case  related  by  Dr.  Thormann  (Wien.  Med. 
Wochnschr.,  1853).  The  cyst  projected  into  the  retro-uterine  pouch, 
and  under  expulsive  efforts  it  burst  through  a  rent  in  the  posterior 
wall  of  the  vagina,  an  arm  of  the  foetus  protruding. 

In  most  cases,  however,  the  cyst  is  too  tough  to  burst.  After  labor- 
pains  have  persisted  for  some  time,  the  foetus  dies. 

Death  may  happen  through  exhaustion  under  the  efforts  at  labor, 
and  from  compression  of  the  foetus  upon  the  abdominal  organs. 

The  peritonitis  may  prove  fatal,  and  the  cause  may  escape  detection 
unless  a  post-mortem  examination  be  made.  Peritonitis  may  be 
the  result  of  rupture  or  perforation  of  the  sac,  and  it  may  precede  or 
follow  the  death  of  the  foetus.  In  one  case  of  this  kind  which  I  liave 
related,^  a  fluctuating  swelling  was  formed  behind  the  uterus.  The 
uterus  was  driven  forwards  and  above  the  symphysis  pubis,  and  con- 
siderably elongated,  I  believe  by  the  pressure  to  which  it  had  thus  long 
been  subjected.  The  absence  of  uterine  pregnancy  was  first  established 
by  the  uterine  sound,  and  by  dilating  the  cervix  to  facilitate  explora- 
tion of  the  interior.  Then  the  swelling  behind  the  uterus  was  punc- 
tured. Fluid  in  part  resembling  liquor  amnii  escaped.  Death  Avas 
caused  by  the  peritonitis.  In  most  cases,  probably,  the  sac  will  en- 
croach upon  the  pelvic  cavity,  getting  behind  the  uterus.  The  sound 
will  isolate  the  uterus;  the  finger  exploring  by  vagina  and  rectum  will 
detect  the  fluctuating  mass,  perhaps  make  out  parts  of  the  foetus,  or 
foetal  bones.  When  this  is  done,  puncture  by  rectum  or  vagina  should 
be  made. 

In  many  cases,  the  sac-walls  being  formed  in  part  by  some  portion 
of  the  alimentary  canal  or  the  abdominal  wall,  or  at  least  only  sepa- 
rated from  these  by  adhesions,  a  process  of  ulcerative  absorption  takes 
place,  by  which  a  fistulous  perforation  is  made  into  the  intestines,  or 

1  St.  Thomas's  Hospital  Keports,  1871. 


378  EXTEA-UTERINE    GESTATIOIST. 

through  the  abdominal  wall.  This  process  is  attended  by  hectic  or 
irritative  fever  and  emaciation.  It  is  rarely  that  the  opening  thus 
made  is  large  enough  to  permit  the  easy  or  complete  evacuation  of  the 
foetus.  The  attempt  at  elimination  is  a  long,  tedious,  and  exhausting 
process,  under  which  the  patient  commonly  sinks. 

When  such  an  opening  is  formed  through  the  abdominal  wall,  it  is 
advisable  to  enlarge  it  by  incision  with  a  bistoury,  so  as  to  give  free 
exit  to  the  remains  of  the  foetus,  which  should  even  be  extracted  by 
the  lingers  or  forceps.  The  opening  may  be  safely  dilated  to  the  neces- 
sary extent  for  this  purpose,  because  the  sac  will  almost  certainly  have 
contracted  large  adhesions  for  some  distance  around. 

In  the  case  of  pointing  and  perforation  into  the  rectum  taking  place 
a  similar  course  should  be  pursued ;  but  the  extension  of  the  opening 
must  be  more  limited.  In  either  case,  during  the  voiding  of  the  foetal 
bones,  and  after  they  have  been  all  collected,  if  an  oiFensive  discharge 
continue,  the  cavity  of  the  sac  may  be  washed  out  from  time  to  time 
by  injecting  a  weak  solution  of  permanganate  of  potash  or  carbolic 
acid. 

Occasionally,  but  less  frequently,  elimination  takes  place  by  the 
bladder.  In  this  case  it  may  become  necessary  to  dilate  the  urethra, 
which  is  easily  done,  so  as  to  admit  the  finger  or  a  lithotomy  forceps, 
to  facilitate  removal  of  bones. 

Another  issue  of  abdominal  and  tubo-ovarian  gestation  is  the  carry- 
ing to  term,  when  signs  of  labor  supervene.  The  phenomenon  offers 
points  of  remarkable  ])hysiological  and  clinical  interest.  It  ought  to 
throw  considerable  light  upon  the  vexed  problem — What  is  the  cause  of 
labor  ?  If  unmistakable  labor-effort  occur  when  the  foetus  is  inclosed 
in  a  sac  quite  independent  of  the  womb,  we  are  entitled  to  exclude  the 
womb  as  the  primary  seat  of  the  cause  of  labor.  And,  as  we  cannot 
ascribe  to  the  artificial  womb  in  which  the  foetus  happens  to  be  con- 
tained, greater  virtue  than  the  natural  womb  possesses,  we  are  driven 
to  conclude  that  the  primary  cause  of  labor  lies  in  the  foetus,  unless 
Ave  imagine  some  power  resident  in  the  mother.  But  this  last  hypoth- 
esis seems  difficult  to  admit.  I  rather  incline  to  the  opinion  that  when 
the  foetus  has  attained  its  full  development,  when  its  organs  are  pre- 
pared for  external  life,  some  change  takes  place  in  its  circulation  which 
involves  a  correlative  disturbance  in  the  maternal  circulation  which 
excites  the  attempt  at  labor.  Sometimes,  even,  a  sanguineous  show 
takes  place  from  the  vagina. 

The  seat  of  the  labor-pains  is  not  even  clear  in  these  cases.  Velpeau 
believed  the  seat  of  the  contractions  to  be  the  foetal  cyst.  If  the  cyst 
be  formed  by  the  Fallopian  tube,  its  muscular  wall  may  be  so  de- 
veloped as  to  possess  true  contractile  power.  The  same  remark  applies 
if  the  sac  be  developed  between  the  layers  of  the  broad  ligament. 
Dezeimeris  thought  the  contraction  was  in  the  uterus,  which,  in  tubal 
cases  at  least,  is  sufficiently  developed.  In  a  tubo-ovarian  case  which 
had  passed  into  the  abdominal  form,  the  constitution  of  which  I  in- 
vestigated with  Dr.  Hall  Davis  and  Dr.  Cayley,  abundant  smooth 
muscular  fibres  were  found  in  the  walls  of  the  sac. 


♦>  ABDOMINAL.  379 

Whenever  the  sac  takes  its  origin  in  or  involves  the  tube,  broad  lig- 
ament, or  ovary,  we  may  expect  to  find  muscular  fibres  in  its  walls. 

Whatever  the  initial  cause  of  labor,  the  attempt  is  necessarily  abor- 
tive. The  pains  subside,  notwithstanding  all  the  help  derived  from  a 
duly  irritable  nervous  centre,  excited  by  impressions  emanating  from 
the  foetus  or  its  sac,  and  often  vigorously  seconded  by  emotional  and 
voluntary  actions.  Under  these  the  sac  may  burst.  Perhaps  the  at- 
tempt is  renewed  at  several  intervals. 

Under  these  circumstances,  what  is  the  best  course  to  pursue  ?  It 
is  not  necessary  to  say,  that  in  the  first  place,  accurate  knowledge 
should  be  obtained  as  to  the  state  of  the  uterus.  Is  it  certain  the 
uterus  has  no  concern  in  the  pregnancy  ?  It  is  proper,  I  think,  in  all 
cases,  to  dilate  the  cervix,  so  as  to  permit  full  exploration  of  the  cavity. 
And  this  exploration  should  be  especially  circumspect  and  deliberate, 
for  although  we  may  be  sure  that  the  cavity  so  examined  is  empty  and 
has  nothing  to  do  with  the  pregnancy,  the  uterus  may  be  double ;  the 
unexplored  cavity  may  contain  the  foetus ;  or  the  gestation  may  be 
interstitial,  that  is,  in  one  horn  of  the  uterus. 

The  foetus  dies  in  many  cases  probably  of  asphyxia ;  in  others  from 
hemorrhage  into  the  placenta.  Large  clots  were  found  in  the  placenta 
by  Koeberle.^ 

Supposing  that  we  are  able  to  exclude  all  forms  of  uterine  gestation, 
ought  we  to  undertake  to  deliver,  and  how  shall  we  do  it?  It  will 
help  us  to  answer  this  question  if  we  examine  the  results  that  may 
occur  if  nothing  be  done.  The  foetus  dies,  the  vascular  system  which 
was  brought  into  activity  for  its  support  becomes  atrophied ;  the  sac 
assumes  the  character  of  an  inert  mass ;  the  system  accommodates 
itself  more  or  less  to  the  burden,  and  things  may  go  on  for  an  indefinite 
time.  There  are  instances  of  women  having  carried  an  extra-uterine 
gestation  for  forty,  even  fifty  years,  ultimately  dying  of  independent 
disease  or  old  age.  The  sac  may  become  calcareous,  or  retain  its  soft 
structure ;  but  it  is  almost  always  found  intimately  adherent  to  ab- 
dominal viscera.  The  foetus  may  undergo  one  of  several  changes ;  for 
several  years  the  fleshy  parts  may  be  preserved,  the  skin  retaining 
much  of  its  original  character,  and  the  muscles  also.  The  surface, 
however,  is  generally  converted  into  adipocere.  After  a  further  time, 
the  soft  tissues  having  first  undergone  this  fatty  metamorphosis,  break 
down,  leaving  the  bones  bare.  These  next  Become  separated.  The 
cyst-walls  inflame  and  suppurate,  and  a  fistulous  communication  is 
opened  with  the  exterior  of  the  body,  or  with  the  bowels. 

If  the  attempt  at  elimination  be  towards  the  surface  by  the  abdomi- 
nal wall,  the  skin  becomes  red,  a  tumor  forms  which  becomes  fluctu- 
ating ;  there  is,  in  fact,  an  abscess,  which  will  burst  if  it  be  not  opened. 
Considerable  irritative  fever  attends  the  process ;  pus  escapes  from  the 
opening  at  first,  and  it  may  be  long  before  any  part  of  a  foetus  is  recog- 
nized. A  probe  should  be  introduced  to  feel  for  solid  substances ;  and 
the  opening  should  be  eidarged  by  the  bistoury  to  permit  the  freer 
exit  of  the  bones.     Every  bone  should  be  carefully  preserved  to  re- 

1  "  A  Memoir  on  Extra-Uterine  Gestation,"  by  Keller.      Strasburg,  1872. 


380  EXTRA-UTERINE    GESTATION. 

construct  the  skeleton  if  possible,  and  thus  to  satisfy  ourselves  as  to 
the  progress  of  the  case. 

If  the  attempt  be  made  by  the  bowel,  commonly  some  distress  in 
defecation  arises,  perhaps  obstruction  of  the  bowel,  then  sanguineous 
discharge  or  dysenteric  symptoms.  Pelvic  inflammatory  symptoms 
attend.  If  examination  be  made  by  the  rectum,  a  projecting  tumor 
may  be  felt,  and  through  its  walls  we  may  make  out  solid  bones.  If 
this  be  clearly  established,  it  is  advisable  to  puncture  the  sac  at  once 
by  a  bistoury  or  large  trocar,  and  to  aid  the  exit  of  the  bones  by 
fingers  or  forceps.  There  is  a  great  advantage  in  the  rectal  elimination, 
if  a  sufficiently  free  opening  be  made.  The  drainage  is  more  easy  and 
perfect  from  the  most  dependent  part  of  the  sac  being  opened,  and 
there  is  a  greater  tendency  to  contraction  and  obliteration.  Accord- 
ingly, a  fair  proportion  of  recoveries  have  followed  this  issue.  Still, 
a  great  hazard  of  exhaustion  by  purulent  discharges  and  septicsemia 
is  incurred. 

Or,  in  other  cases,  the  foetus  undergoes  a  calcareous  metamorphosis. 
This  seems  the  change  most  compatible  with  long  life  of  the  mother. 
There  is  a  specimen  in  St.  Thomas's  Museum,  for  which  I  am  indebted 
to  Mr.  R.  W.  Watkins,  of  Towcester.  The  foetus  had  been  retained 
for  forty-three  years.  It  is  an  admirable  specimen  of  what  is  called 
"  Lithopsedion,"  or  conversion  of  the  foetus  into  stone.  (See  "  Obstet- 
rical Transactions,"  vol.  viii.) 

But  this  conversion  of  the  foetus  into  a  harmless  mass  must  be  re- 
garded as  a  rare  and  fortunate  accident.  Various  circumstances  may 
arise  to  disturb  the  tran(][uillity  of  the  sac,  light  up  inflammation,  and 
bring  about  dangerous,  even  fatal  changes.  A  not  uncommon  circum- 
stance thus  acting,  is  a  subsequent  uterine  pregnancy.  The  enlarged 
uterus  may  press  upon  the  foetal  sac,  and  thus  mischief  may  arise  even 
during  pregnancy.  But  the  period  of  labor  is  especially  perilous. 
During  the  expulsion  of  the  uterine  child,  the  extra-uterine  sac  is  ex- 
posed to  severe  pressure.  Possibly,  this  sac  may  be  fixed  low  down 
near  the  pelvic  brim,  and  be  a  direct  obstacle  to  labor.  Accordingly, 
the  histories  of  many  cases  show,  that  a  supervening  uterine  labor  has 
kindled  the  dormant  mischief,  and  caused  death.  Cases  are  however 
known,  in  which  women,  carrying  an  extra-uterine  foetus,  have  gone 
through  a  second  and  even  several  labors.  They  rarely  escape  in  the 
long  run.  The  danger  is  so  great  that  it  ought  to  influence  our  course 
of  action. 

I  have  stated  my  opinion  that  rupture  of  a  tubal  gestation-sac  is 
not  necessarily  fatal.  The  blood  effused  may  flill  into  the  retro-uterine 
pouch,  become  segregated  there,  whilst  the  remains  of  the  sac,  with  or 
without  the  embryo,  may  be  shut  off  from  the  general  peritoneal  cavity 
by  plastic  effusions,  and  shrivel  up.  This  view  is  confirmed  by  a  re- 
markable case  published  in  the  '^  Obstetrical  Transactions,"  1864,  by 
Dr.  Haydon,  tlie  specimen  being  reported  upon  by  Drs.  Tyler  Smith 
and  Braxton  Hicks.  A  young  woman  became  i3regnant,  and  was  sup- 
posed to  have  aborted,  but  no  foetus  was  seen.  She  was  at  the  time 
dangerously  ill,  and  not  expected  to  live.  Four  or  five  years  later  she 
again  incurred  the  risk  of  pregnancy,  and  six  months  afterwards  died 


ABDOMINAL.  '  381 

under  symptoms  of  internal  abdominal  rupture.  A  gestation-sac  in 
the  right  tube  had  burst,  and  a  foetus  of  three  months'  development 
had  escaped  :  and  appended  to  the  edge  of  the  rent  was  a  small  irreg- 
ular solid  mass,  which  proved  to  be  a  small  foetus  packed  very  tightly 
within  a  membrane.  Tlie  conclusion  drawn  was  that  the  patient  had 
had  two  distinct  tubal  gestations ;  that  the  first  ended  in  rupture  and 
isolation  with  shrinking  of  the  embryo ;  that  the  second,  occurring 
some  years  afterwards,  ended  by  fatal  rupture  of  the  sac  six  months 
after  conception,  the  embryo  having  died  three  months  before  the 
rupture. 

Diagnosis  of  Abdominal  Gestation  from  Ovarian  Tumor  and  Normal 

Gestation. 

The  recognition  of  freely  fluctuating  ovarian  tumors  is  easy ;  but  I 
have  several  times  experienced  great  difficulty  when  the  tumor  was  in 
great  part  solid.  Ovarian  tumors  are  occasionally  irregular  in  shape, 
and  present  hard  projections  which,  if  the  mind  is  occupied  with  the 
idea  of  pregnancy,  are  readily  mistaken  for  foetal  limbs.  After  the 
utmost  pains  have  been  expended  in  order  to  arrive  at  a  conclusion,  an 
exploratory  incision  may  offer  the  only  satisfactory  information. 

As  to  the  diagnosis  of  one  form  of  extra-uterine  gestation  from  an- 
other, Scanzoni  declares  that  this  is  impossible  during  life.  This  must 
be  taken  witli  some  qualification.  The  abdominal  form  at  least  may 
commonly  be  distinguished  from  the  tubal  by  its  greater  development, 
by  its  longer  history,  and  by  its  terminations. 

The  abdomen  is  generally  less  tense  than  in  normal  gestation ;  it  is 
expanded  transversely;  the  umbilicus  is  often  strongly  drawn  in.  The 
foetal  movements  may  be  felt  very  distinctly,  and  are  often  more  vio- 
lent than  in  ordinary  gestation.  The  placental  souffle  is  very  rarely 
heard.  The  os  uteri  may  feel  like  that  of  the  pregnant  uterus,  the 
cervix  being  open.  The  body  of  the  uterus  is  likely  to  be  deflected  to 
one  side,  and  possibly  fixed  by  adhesions.  This  fixing  of  the  uterus, 
infinitely  rare  in  uterine  gestation,  would  raise  a  strong  presumption  in 
favor  of  extra-uterine  gestation.  In  almost  all  these  cases  the  uterus 
is  elongated.  This  elongation  and  the  direction  imparted  to  the  organ 
will  be  defined  by  the  sound,  if  the  circumstances  seem  to  justify  the 
use  of  this  instrument. 

When  the  foetus  is  dead,  the  abdomen  sinks;  the  breasts  fall;  the 
uterus  resumes  its  ordinary  state,  remaining,  however,  somewhat  above 
its  normal  length.  The  history  will  help.  The  subject  will  have  been 
conscious  of  being  pregnant.  There  will,  in  all  probability,  have  been 
indications  of  attacks  of  peritonitis. 

The  question  of  treatment  has  to  be  discussed  under  four  different 
aspects. 

1st.  Under  the  condition  of  early  rupture,  gastrotoray  might,  as  we 
have  seen  when  dealing  with  tubal  gestation,  be  resorted  to  with  a  view 
to  stopping  the  hemorrhage.  Velpeau,  Duparcque,  Kiwisch  advised 
it.     Koeberl^  says  he  would  not  hesitate  to  do  it. 


382  EXTEA-UTEEINE    GESTATION. 

2d.  When  the  stage  of  danger  of  rupture  has  passed;  that  is,  after 
the  fourth  month. 

3d.  When  labor  supervenes  at  term. 

4th.   When  hibor  has  passed  over  and  the  child  is  dead. 

What  is  to  be  done  daring  the  life  of  the  child  ?  Shall  we  wait, 
pursuing  simply  an  expectant  course,  or  shall  we  take  means  to  kill  the 
child,  so  as  to  stop  the  developmental  stimulus,  trusting  to  the  reduc- 
tion of  the  sac,  to  isolation  from  the  general  system,  and  atrophy,  or 
shall  we  resort  to  abdominal  section,  or  other  sure  way  of  opening  the 
foetal  cyst  so  as  to  extract  the  child?  The  decision  is  extremely  diffi- 
cult. During  the  developmental  stimulus,  the  sac  and  surrounding 
structures  are  full  of  blood.  To  make  incisions  into  them  at  this  time, 
or  even  to  puncture  them,  is  attended  with  serious  danger  from  hemor- 
rhage. If  the  opportunity  of  tapping  the  sac  at  an  early  date  has  gone 
by,  I  think  it  will  be  better  not  to  disturb  the  sac  until  the  full  term 
of  pregnancy  has  arrived,  when  labor-effort  is  present,  or  when  we 
know  the  child  is  dead.  In  one  case^  Dr.  B.  Hicks  having  felt  a  foetus 
of  about  three  and  a  half  months  in  a  cyst  between  the  rectum  and 
the  vagina,  tried  to  destroy  it  by  passing  a  strong  galvanic  current 
through  it.  Although  the  foetal  movements  ceased  during  the  admin- 
istration, the  embryo  survived.  A  month  later  Dr.  Hicks  passed  a 
small  trocar  into  it.  On  the  fourth  day  the  patient  died  under  symp- 
toms of  internal  hemorrhage.  Two  pints  of  fluid  blood  were  found  in 
the  peritoneum.  Duchenne's  plan  of  giving  a  shock  from  a  Leyden 
jar  might  have  answered  better. 

What  is  to  be  done  when  the  natural  term  of  gestation  arrives,  the 
child  being  alive?  New  dangers  now  arise.  The  cyst  may  burst. 
There  is  renewed  danger  of  hemorrhage,  and  of  peritonitis.  And,  not 
seldom,  accidents  follow  quickly  on  the  death  of  the  child.  The  cyst 
has  on  several  occasions  burst  during  the  early  days  following  false 
labor,  and  acute  peritonitis  has  pro vecl  fatal.  To  obviate  these  dangers, 
Levret  advised  gastrotomy.  So  did  Gardien,  saying  the  placenta  might 
be  left.  Yelpeau  and  Kiwisch  also  advised  it.  Keller,  who  repre- 
sents the  opinions  of  Koeberle,  is  in  favor  of  the  proceeding.  He  cites 
nine  cases  in  which  this,  the  primary  operation,  was  performed,  seven 
children  and  four  mothers  being  saved.  He  adds  an  account  of  eight 
other  cases,  in  which  the  operation  might  have  been  performed  with  ad- 
vantage, the  opportunity  being  lost. 

It  must,  however,  be  remembered  that  in  a  large  proportion  of  cases 
the  labor  subsides,  the  dead  child  is  tolerated,  and  for  a  time  at  least 
the  mother  goes  on  without  serious  distress.  It  is  true  another  phase 
of  danger  succeeds,  but  the  period  for  this  may  be  remote.  Looking 
first  to  the  mother's  safety,  I  think  we  must  decide  that  this  is  best 
attained  by  not  resorting  to  any  operation  to  remove  the  child.  The 
rule  of  action  maybe  expressed  as  follows:  If  the  labor-symptoms 
subside  without  sign  of  grave  injury  or  hemorrhage,  do  not  interfere. 
If,  on  the  other  hand,  there  arise  evidence   of  severe  injury,  which,  if 

1  "  Obstetrical  Transactions,"  1866. 


ABDOMINAL.  383 

left  alone,  would  probably  be  followed   by  fatal  shock,  peritonitis,  or 
exhaustion,  open  the  abdomen  and  remove  the  foetus. 

A  weighty  objection  against  opening  the  sac  to  remove  the  child 
whilst  alive  or  recently  dead,  rests  on  the  uncertainty  as  to  the  nature 
of  the  sac.  In  some  abdominal  cases  it  can  hardly  be  said  that  a  true 
sac  with  defined  walls  exists;  the  placenta  may  adhere  directly  to  the 
back  of  the  uterus,  to  the  surface  of  the  intestines,  even  partly  to  the 
kidney,  or,  as  in  a  case  of  Koeberle,  to  the  anterior  abdominal  wall,  so 
that  it  was  divided  in  the  incision  necessarily  made  to  open  the  cyst. 
It  may  be  almost  impossible  to  cut  down  upon  the  foetus  without  dis- 
turbing attachments  to  such  an  extent  as  to  produce  hemorrhage  that 
would  probably  be  fatal.  The  case  differs  essentially  from  that  of  the 
Caesarian  section.  The  extra-uterine  sac  does  not  possess  the  conserva- 
tive contractile  property  of  the  uterus. 

In  gastrotomy  for  extra-uterine  gestation  none  of  the  favorable  con- 
ditions proper  to  the  Caesarian  section  are  present.  The  jDlacenta  is 
almost  always  much  spread  out,  and  sometimes  very  adherent  More- 
over, if  the  extraction  of  the  placenta  were  possible,  would  it  be  pru- 
dent to  eifect  it  ?  The  placental  insertion  is  not  endowed  with  con- 
tractility as  in  uterine  gestation ;  the  maternal  sinuses  will  remain  gap- 
ing, and  hemorrhage  will  be  great.  This  objection  to  gastrotomy 
whilst  the  child  is  living,  loses  some  of  its  force  if  the  attachments  of 
the  placenta  are  religiously  respected,  as  the  greater  number  of  operators 
have  understood  the  necessity  for  doing.  Its  elimination  is  then 
effected  slowly,  and  the  maternal  vessels  have  time  to  contract  and  to 
become  obliterated. 

The  most  serious  dangers  of  gastrotomy  performed  at  term  are  those 
which  the  elimination  of  the  afterbirth  may  provoke,  that  is  to  say, 
secondary  hemorrhage,  peritonitis,  and  septicaemia.  But  are  these  as 
great  and  real  as  they  appear  at  first  sight?  In  the  first  place  the 
peritoneum  is  not  always  opened;  the  cyst  has  contracted  adhesions 
Avith  the  abdominal  walls.     Thus  argues  Keller. 

If  an  expectant  plan  be  followed,  if  opium  and  perfect  rest  be  em- 
ployed, the  vascularity  of  the  sac  and  the  organs  connected  with  it 
gradually  diminishes,  menstruation  returns,  a  degree  of  contraction 
takes  place,  and  after  a  time  probably  further  adhesions  tend  to  com- 
plete the  isolation.  Still  the  patient's  life  may  be  said  to  be  at  the 
mercy  of  accidents,  of  which  we  may  have  no  sufficient  warning.  The 
cyst  may  still  rupture,  or  fatal  peritonitis  may  ensue.  If  uterine  preg- 
nancy supervene  the  situation  may  quickly  become  critical. 

If  it  be  decided  not  to  operate  during  labor,  what  is  the  alternative  ? 
Shall  Ave  operate  soon  after  the  child's  death?  If  the  mother  is  suffer- 
ing, exhausted,  in  great  pain,  and  adhesions  be  diagnosed,  it  may  be 
Avise  to  operate  witiiin  a  few  days.  The  placenta  soon  ceases  to  be  a 
source  of  much  danger.  Its  circulation  has  ceased.  The  blood  coagu- 
lates in  its  villosities  as  was  observed  by  Koeberle. 

If  Ave  decide  to  wait,  the  patient  should  be  kept  under  A'igilant  ob- 
servation. We  should  be  ready  to  act  the  moment  any  sign  of  rupture 
or  shock  occurs.  When  an  eliminative  process  begins,  the  propriety  of 
interfering  is  clear,  especially  if  irritative  fever,  set  in.     The  seat' for 


384  EXTE.A-DTEEINE    GESTATION. 

operative  measures  will  commonly  be  indicated  by  the  seat  of  the  elim- 
inative  molimen.  If  there  be  pelvic  distress,  such  as  obstruction  or 
irritation  of  the  rectum,  crowding  the  uterus  forwards  upon  the  blad- 
der, causing  retention  of  urine,  with  or  without  local  inflammation,  and 
if  we  can  detect  parts  of  the  foetus  or  a  prominent  fluctuating  tumor 
between  the  rectum  and  the  vagina,  this  is  the  place  to  select.  An 
opening  may  be  made  first  with  a  large  trocar,  and  any  fluid  contents 
of  the  sac  be  allowed  to  drain  off.  A  sound,  or  the  finger  introduced 
through  the  opening,  may  detect  the  foetus  or  bones.  Opportunity 
may  first  be  aflbrded  for  the  spontaneous  evacuation  of  the  foetus  piece- 
meal. If  this  does  not  proceed  satisfactorily,  no  great  time  should  be 
lost  before  enlarging  the  opening  with  a  bistoury ;  and,  if  feasible,  of 
extracting  the  foetal  parts  by  finger  or  forceps. 

In  some  cases  the  eliminative  eifort  is  directed  to  the  roof  of  the 
vagina.     In  this  event  we  equally  adopt  the  route  offered  by  nature. 

If  the  eifort  be  directed  to  the  abdominal  wall,  the  usual  signs  of 
abscess  mark  the  point  selected.  The  most  common  places  are  the 
neighborhood  of  the  umbilicus,  one  or  other  flank  about  midway 
between  the  umbilicus  and  the  anterior  superior  spinous  process  of 
the  ilium,  or  a  groin.  In  some  cases  a  perforation  may  have  taken 
place  into  the  bowel  or  vagina,  and  there  may  also  be  eliminative 
effort  towards  the  abdomen.  The  communication  with  the  bowel 
may  be  at  a  point  quite  out  of  reach  of  examination  by  the  rectum. 
In  such  cases  the  indication  is  to  operate  through  the  abdominal  wall. 
It  is  not  constant  that  an  inflammatory  process  takes  place  between 
the  sac  and  the  abdominal  wall.  But  there  is  almost  universally 
increase  of  prominence  at  some  part  of  the  abdomen.  If  air  get  into 
the  sac  from  the  abdomen,  and  I  suspect  sometimes  without,  decomposi- 
tion proceeds  rapidly,  putrefactive  gases  distend  the  tumor,  suppura- 
tion proceeds;  and  we  then  get  resonance  over  the  projecting  part  of 
the  tumor,  and  fluctuation  at  other  parts.  Probably  pus  may  be  dis- 
charged by  the  bowel.  With  these  local  symptoms  there  will  be  hectic 
marked  by  rigors,  sweats,  diarrhoea,  perhaps  vomiting,  a  quick,  Aveak 
pulse.  When  this  concourse  of  symptoms  is  found,  there  can  be  no 
doubt  as  to  the  expediency  of  trying  to  relieve  the  patient.  Extraction 
of  the  foetus  and  giving  issue  to  the  offensive  contents  of  the  sac  may 
save  her  life.  Accordingly,  there  are  many  instances  where  this  course 
has  been  successfully  pursued. 

Mr.  Hutchinson,  who  has  studied  this  question  with  great  care,  and 
based  his  conclusions  upon  the  comparison  of  all  the  cases  he  could 
collect,^  is  of  opinion  that  what  may  be  called  the  primary  operation 
by  abdominal  section  should  not  be  jierformed,  but  that  the  secondary 
abdominal  section,  i.  e.,  at  a  time  remote  from  the  death  of  the  foetus, 
when  inflammation  of  the  sac  has  occurred,  is  strongly  indicated.  Camp- 
bell, who  collected  eighty-five  cases  of  extra-uterine  gestation,  showed 
that  sixty-two  recovered,  whilst  twenty -three  died  as  a  direct  conse- 
quence of  the  abnormal  pregnancy.  Of  the  sixty-two  in  which  recovery 
took  place,  in  twenty-one  tiie  foetus  remained  quiescent  through  life  for 


1  Medical  Times  and  Gazette,  1860. 


ABDOMINAL.  385 

periods  varying  from  four  to  fifty-six  years,  and  in  the  rest  its  removal 
had  been  effected  by  ulceration.  In  a  not  inconsiderable  number  of 
the  latter,  the  natural  processes  had  been  materially  assisted  by  the 
surgeou,  as  by  extracting  bones,  enlarging  the  opening,  and  so  forth. 

Campbell  advised  that  abdominal  section  should  not  be  performed 
until  "  after  the  system  had  been  restored  to  its  unimpregnated  condi- 
tion, and  nature  had  evinced  a  disposition  to  remove  the  extraneous 
mass." 

Study  of  the  facts  published  since  Mr.  Hutchinson  made  his  collec- 
tion, confirms  me  in  the  opinion  that  he  is  right  in  his  conclusion,  that 
"the  longer  the  operation  is  deferred,  and  the  longer  continued  the  in- 
flammation of  the  cyst  has  been,  the  more  likely  is  it  that  the  incision 
will  open  merely  an  abscess  cavity,  from  which  the  peritoneal  sac  will 
be  shut  off;"  and  that  the  prospect  of  the  operation  being  successful  is 
pro  tanto  increased. 

At  the  same  time  it  does  not  seem  desirable  absolutely  to  condemn 
the  primary  operation  ;  still  less  the  operation  at  a  time  remote  from 
the  death  of  the  foetus,  even  when  no  inflammatory  or  elimiuative  effort 
has  presented  itself.  I  do  not  think  the  risk  of  danger  from  subse- 
quent uterine  pregnancy  is  sufficiently  weighed.  At  all  events  the 
subject  of  an  extra-uterine  gestation  should  be  emphatically  cautioned 
not  to  incur  the  risk  of  another  pregnancy.  In  the  event  of  this  com- 
plication occurring,  the  case  should  be  treated  on  the  same  principle 
as  those  laid  down  when  discussing  the  treatment  of  ovarian  tumors 
complicated  with  pregnancy. 

Very  eminent  men  have  advised  the  primary  operation.  Thus  Lev- 
ret,  Gardien,  Velpeau,  and  Kiwisch  urged  it,  and  that  at  a  time  when 
abdominal  surgery  was  imperfectly  understood,  when  its  dangers  were 
really  greater  than  now,  and  when  they  were  thought  to  be  even  greater 
still.  In  recent  times,  Koeberle,  whose  authority  is  especially  to  be 
valued  on  account  of  his  great  experience  and  success  in  ovariotomy 
and  in  gastrotomy  for  extra-uterine  gestation,  pronounces  himself  de- 
cidedly in  favor  of  the  proceeding.  Dr.  Keller,  the  author  of  an  ex- 
cellent memoir  on  extra-uterine  gestation,^  after  carefully  weighing  the 
arguments,  for  and  against,  decides  in  favor.  He  calls  to  mind  that 
dangerous  accidents  may  ensue  quickly  upon  the  child's  death ;  that 
the  cyst  has  on  several  occasions  burst  during  the  early  days  of  false 
labor ;  and  that  hemorrhage  and  peritonitis  may  quickly  prove  fatal. 
Mr.  Lawson  Tait,  who  has  recently  performed  the  operation  three 
months  after  term,  found  the  child's  head  in  the  pelvic  cavity  adherent 
to  the  cyst.  He  urges  the  probability  of  this  accident  as  a  reason  for 
operating  before  term,  or  as  soon  as  possible  after  it.  His  patient  re- 
covered quickly  after  the  placenta  was  discharged. 

On  the  other  hand,  it  must,  I  think,  be  admitted  that  the  risks 
attending  the  primary  operation  are  greater  than  those  attending  the 
secondary  operation.  Whilst  the  child  is  alive,  the  cyst  and  placenta 
are  in  the  full  vigor  of  vascular  communication ;  the  cyst  has  probably 

1  "  Des  Grossespes  extra-uterines,  et  plus  specialement  de  leur  traitement  par  la 
gastrotomie."      Paris,  1872. 

25 


386  EXTRA-UTEEIXE     GESTATION. 

no  contractile  property ;  the  placenta  is  likely  to  be  widely  diffused,  its 
attachments  projecting  amongst  intestines,  perhaps  deep  in  the  pelvis ; 
or  it  may,  as  occurred  in  a  case  operated  upon  by  Koeberle,  grow  to 
the  anterior  wall  of  the  abdomen,  so  that  it  must  necessarily  be  cut 
through  by  the  incision  made  to  open  the  cyst.  The  cyst  itself  has 
probably  not  formed  extensive  adhesions  to  the  abdominal  wall,  so  that 
incision  will  be  likely  to  open  the  peritoneum.  There  will  thus  be  greater 
danger  of  secondary  hemorrhage,  of  suppuration,  of  septicaemia,  and  of 
peritonitis.  On  these  and  other  grounds  the  primary  operation  has 
been  opposed  by  Gerdy,  Delpech,  Hutchinson,  and  others. 

It  is  premature,  I  think,  to  lay  down  an  absolute  rule.  Generally, 
the  primary  operation  is  certainly  more  dangerous  than  the  secondary. 
But  this  is  not  all  we  have  to  consider.  The  question  would  be  fairly 
stated  as  follows:  Are  the  dangers  of  the  primary  operation  greater 
than  those  of  the  secondary  operation,  plus  the  dangers  immediately 
and  soon  following  the  neglect  to  perform  the  primary  operation  ?  It 
is  clear  that  the  catastrophes,  as  rupture  of  the  cyst,  hemorrhage,  and 
peritonitis  attending  false  labor,  must  be  taken  into  account,  and  added 
to  the  dangers  of  the  secondary  operation.  It  is  also  right  to  throw 
into  the  same  scale  at  least  a  certain  proportion  of  the  more  remote  dan- 
gers, as  peritonitis,  exhaustion  from  suppuration,  subsequent  uterine 
pregnancy,  and  so  on,  to  which  the  woman  is  exposed. 

If  rupture  occurs,  if  the  w^oman  is  obviously  suffering  intensely, 
when  the  gestation  is  at  term,  there  ought,  I  think,  to  be  no  hesitation 
in  operating  in  the  hope  of  removing  the  source  of  irritation. 

The  Operation  of  Gastrotomy  to  Remove  an  Extra-  Uterine  Foetus. — 
The  general  preparations  are  the  same  as  for  the  Csesarian  section ; 
but  there  are  important  modifications  in  the  execution. 

The  seat  of  the  incision  will  generally  be  in  the  linea  alba.  It  is, 
however,  determined  somewhat  by  the  point  of  greatest  prominence  of 
the  tumor,  or  by  the  position  of  the  foetus.  A  smaller  incision  is 
commonly  necessary  than  for  the  Csesarian  section.  The  central  j)oint 
of  pain  and  prominence  is  the  most  likely  to  be  the  centre  of  the  ad- 
hesions formed  between  the  sac  and  the  alxlominal  wall.  A  longitudi- 
nal incision,  not  exceeding  two  inches  in  length  in  the  first  instance,  is 
then  carried  carefully  through  the  abdominal  wall,  and  a  small  open- 
ing is  made  in  the  sac.  The  finger  is  passed  through  this  to  feel  for 
the  limit  of  the  adhesions,  and  guide  the  further  extent  and  direction 
of  the  incision.  This  should  be  just  large  enough  to  permit  the  ex- 
traction of  the  foetus ;  and  it  is  better,  if  there  be  any  difficulty  in 
extracting  the  foetus  whole,  to  bring  it  away  piecemeal,  than  to  extend 
the  opening  much,  lest  we  open  the  peritoneal  cavity.  If  the  cyst 
have  not  contracted  adhesions  with  the  abdominal  wall,  care  will  be 
necessary  to  prevent  the  protrusion  of  intestines  and  the  escape  of 
blood  and  other  offending  matters  into  the  peritoneal  cavity.  To  ob- 
viate this,  the  cyst,  at  the  point  where  it  opens  into  the  peritoneum, 
should  be  carefully  stitched  to  the  edges  of  the  abdominal  wound,  so 
as  to  shut  out  the  communication. 

The  extraction  of  the  foetus  may  appear  a  simj:)le  matter,  but  it  re- 
quires some  obstetric  skill  to  do  it  without  unnecessarily  increasing 


ONE-HORNED    GESTATION.  387 

the  opening  or  disturbing  the  sac.  I  have  seen  a  surgeon  pull  at  the 
arms  as  soon  as  the  fcetus  came  in  sight,  and  thus,  not  reflecting  that 
he  was  really  making  a  transverse  presentation,  fail  to  extract  the 
foetus  througii  a  very  liberal  opening.  It  was  instantly  deliv^ered  with 
perfect  ease  by  the  late  Dr.  Ramsbotham,  who  seized  the  feet,  perform- 
ing the  equivalent  of  version. 

The  same  consummate  obstetrist,  Mdio  had  had  considerable  experi- 
ence in  cases  of  extra-uterine  gestation,  insisted  upon  the  rule  now 
generally  adopted,  of  not  removing  the  jjlacenta,  if  it  in  any  degree 
adhere.  It  is  advisable  to  tie  the  funis,  and  let  its  end  hang  out  of 
the  wound.  If  omentum  interfere,  the  obtruding  bit  may  be  cut  ofF, 
and  the  vessels  tied,  or,  better  still,  removed  by  cautery-clamp.  Re- 
frain from  all  curiosity  as  to  the  attachment  of  the  placenta  and  other 
matters,  if  it  cannot  be  indulged  without  disturbing  the  parts  or  ex- 
tending the  opening.  If  the  placenta  do  not  come  away  on  gentle 
traction,  leave  it.  In  some  cases  it  wnll  already  have  melted  down, 
and  its  remains  will  come  away  with  the  pus  and  other  discharges. 
In  other  cases  it  softens  and  breaks  down  within  a  few  days  after  the 
operation,  and  will  come  away  in  lumps  or  small  debris.  In  other 
cases  its  attachments  have  yielded  in  a  few  days  as  the  sac  shrank,  and 
it  has  come  away  entire.  Marked  improvement  commonly  follows 
the  discharge  of  the  placenta.  This  last  source  of  irritation  gone,  the 
rally  is  often  quick. 

Where  attempts  have  been  made  to  remove  the  placenta  or  the  cyst, 
the  result  has  generally  been  disastrous,  and  that,  whether  the  case 
were  primary  or  secondary,  whether  the  child  were  alive  or  dead. 

The  wound  may  be  closed  with  two  or  three  sutures,  leaving  a  suf- 
ficient opening  for  the  funis  and  ligatures,  if  any  vessels  had  been  tied. 
If  discharge  continues,  the  sac  may  be  lightly  washed  out  now  and 
then  with  a  solution  of  permanganate  of  potash  or  carbolic  acid.  In 
such  a  case,  when  the  sac  adheres  throughout  the  extent  of  the  open- 
ing, the  operation  is,  as  Mr.  Hutchinson  remarks,  scarcely  more  serious 
than  opening  an  abscess. 

Primary  Opening  of  the  Sao  hy  Caustics. — A  case  is  related'  of  a 
woman  who  had  carried  an  extra-uterine  foetus  ten  months.  Blachet 
opened  into  the  sac  by  five  applications  of  caustic.  No  blood  was  lost ; 
and  the  foetus  was  extracted.  The  patient  nearly  lost  her  life  from  the 
bleeding  which  ensued  on  removing  the  placenta. 

Interstitial  or  Intramural  Gestation,  Gestation  in  One  Horn  of  a  Tido- 
Horned  Uterus,  and  Gestation  in  the  Horn  of  a  Single-Horned 
Uterus. 

It  is  convenient  to  discuss  these  conditions  together.  They  approach 
each  other  so  nearly  in  locality  and  other  characters,  that  they  hardly 
admit  of  distinct  clinical  demonstration.  The  seat  of  these  varieties, 
lying  between  those  of  tubal  gestation  and  uterine  gestation,  must  also 
occasionally  give  rise  to  difficulty  in  discriminating  them  from  the 

1  Gazette  des  Hopitaux,  1856. 


388  EXTEA-UTEEINE    GESTATION. 

latter.  I  entertain  little  doubt,  for  example,  that  some  cases  of  pre- 
sumed "  missed  uterine  labor,"  a  part  of  whose  history  is  the  subse- 
quent discharge  of  foetal  bones  by  the  os  uteri  and  vagina,  were  really 
cases  of  interstitial  gestation,  or  of  gestation  in  one  horn  of  a  two- 
horned  uterus. 

Ulrich,'  however,  relates  a  case,  which  seems  a  genuine  instance  of 
retention  of  foetus  in  utero  for  long  after  its  death.  The  foetus  died  at 
five  months ;  discharge  of  placenta  in  pieces  took  place  by  vagina  four 
months  later,  and  then  bones  came  by  the  same  passage.  A  year  after 
this,  all  escape  of  bones  by  vagina  having  ceased,  bones  passed  per 
anum.  The  patient  died  exhausted.  The  uterus  was  found  adherent 
to  intestine ;  some  bones  were  encapsuled  in  the  wall  of  the  intestine ;  a 
direct  communication  existed  between  uterus  and  intestine.  The  cavity 
of  the  uterus  was  empty.  It  was  concluded  that  the  pregnancy  was 
uterine,  and  that  the  discharge  of  bones  into  the  intestine  was  the  result 
of  a  fistulous  opening  established  from  the  uterus. 

Halley^  relates  a  case  of  a  pluripara,  who,  in  the  middle  of  her  third 
pregnancy,  discharged  offensive  water  and  bones  by  the  vagina.  He 
found  the  uterus  anteverted,  the  cervix  shortened  and  widened,  the  os 
slightly  open.  The  cervix  was  dilated  by  laminaria,  and  twenty-eight 
pieces  of  bone  were  removed.  The  discharge  then  ceased,  and  men- 
struation returned  naturally. 

Ramsbotham  prefers  the  term  "  parietal  "  to  "  interstitial."  It  is  re- 
markable, that  when  gestation  takes  place  in  the  uterine  portion  of  the 
tube,  the  dilatation,  as  a  rule,  affects  solely  the  space  between  the  inner 
and  outer  openings.  The  reason,  Kiwisch  suggests,  may  lie  in  the  cir- 
cular disposition  of  the  muscular  fibres  around  these  openings.  The 
sac  enlarges  most  freely  in  an  outward  direction,  and  forms  a  promi- 
nence with  a  broad  basis  on  the  side  of  the  body  of  the  uterus.  It  is 
surrounded  by  the  uterine  substance,  which  at  first  undergoes  an  eccen- 
tric hypertrophy,  and  later,  as  the  sac  grows  rapidly,  is  stretched, 
thinned  at  its  apex,  and  then  bursts.  Interstitial  gestation  may,  says 
Rokitansky,  in  rare  instances  like  tubal  gestation,  merge  into  abdomi- 
nal gestation.  As  in  gestation  in  a  rudimentary  horn,  it  is  often  im- 
possible to  trace  an  opening  from  the  tube  into  the  sac.  This  becomes 
obliterated  on  either  side  as  the  sac  is  developed.  But  a  peculiar  modi- 
fication at  times  occurs.  The  uterine  mouth  of  the  pregnant  portion  of 
tube  may  be  dilated,  so  that  the  sac  expands  into  the  uterine  cavity, 
constituting  tubo-uterine  gestation,  or  the  tubal  mouth  dilating,  the  sac 
enlarges  in  the  direction  of  the  tube,  constituting  interstitial  tubal  gesta- 
tion. The  first  variety  may  end  in  normal  labor,  whilst  the  latter  is 
likely  to  burst  into  the  abdominal  cavity. 

The  illustration  of  tubo-uterine  or  interstitial  gestation  (Fig.  84)  is 
taken  from  Dr.  Poppel.^  A  pluripara  died  suddenly  under  symptoms 
of  abdominal  collapse  and  internal  bleeding.  She  had  been  unaware 
of  her  pregnancy.  The  uterus  measured  from  fundus  to  os  18  centini., 
at  its  greatest  width  13  centim.     The  right  side  of  the  fundus  was  more 

1  Monatsschrift  fiir  Geburtskunde,  1857.  '■'  Lancet,  1867. 

3  Monatsschrift  fiir  Geburtskunde,  1868. 


INTEESTITIAL. 


389 


protuberant  than  the  left,  and  shoM^ed  at  its  hinder  part  two  rents, 
through  which  were  seen  portions  of  placenta  and  a  foetus.  The  uterus, 
opened  longitudinally  along  its  fore  aspect,  showed  two  cavities.  The 
lower  one  {a  in  Fig.  84)  was  clothed  with  a  thick  decidua.  This  was 
the  proper  uterine  cavity.  The  upper  cavity  (c)  was  divided  from  the 
lower  by  a  septum  of  muscular  structure,  all  but  a  small  opening  of 
communication.  It  contained  a  fresh  foetus,  w^hich  corres])onded  to  the 
fifth  month  of  gestation.  At  the  point  of  the  rupture  the  wall  of  the 
sac  was  very  attenuated,  but  at  cZ  <i  it  was  1|  centim.  thick. 


Fig.  84. 


Tubo-uterine  Gestation.— (After  Poppel.)    One-third  size. 

a,  Cavity  of  uterus  clothed  with  decidua.    b.  Broad  ligament,    c,  Tubo-uterine  sac  which  contained 

foetus,    d,  d,  Thicker  part  of  walls  of  cyst,    e,  Placenta. 

Poppel  discusses  the  difficulty  of  distinguishing  these  cases  from 
gestation  in  a  rudimentary  horn.  Baart  de  la  Faille,  who  has  written 
a  careful  memoir  on  the  subject,^  insists  also  on  this  difficulty.  He 
says,  the  characteristic  distinction  lies  in  this,  that  in  the  case  of  gesta- 
tion in  a  rudimentary  horn  there  is  a  muscular  band  of  union  between 
the  uterus  proper  and  the  fruit-sac  (compare  Poppel's  Fig.  84  with 
Luschka's  Fig.  83),  whilst  in  interstitial  gestation  there  exists  almost 
always  a  membranous  septum  with  a  larger  or  smaller  communication, 
which  is  the  original  opening  of  the  tube. 

Course  and  Terminations  of  Interstitial  Gestation. 

It  is  probably  even  more  dangerous  than  the  tubal  form.  Hecker 
collected  twenty-six  cases.     The  duration  of  gestation  was  generally 

1  "  Verhandeling  over  Graviditas  tubo-uterina."     Groningen,   1867. 


390  ECTOPIC    GESTATION. 

less  than  three  months.  All  terminated  fatally.  The  ovum  arrested 
in  the  uterine  portion  of  the  tube  is  developed  there,  forming  its  sac  in 
the  proper  wall  of  the  uterus ;  hence  it  is  called  graviditas  in  uteri  sub- 
stantid.  It  is  just  conceivable  that  an  ovum  so  placed  might  grow,  in- 
ducing a  corresponding  growth  of  the  muscular  wall  which  surrounds 
it,  mutual  adaptation  proceeding,  as  in  the  case  of  an  intramural  fibroid 
tumor.  I  believe  that  a  fibroid  never  bursts  its  investment  as  an  ovum 
does,  although  Larcher  relates  a  case  in  which  the  uterus  ruptured  with 
a  fibroid  tumor.  This,  no  doubt,  is  due  to  the  quicker  rate  of  growth 
of  the  ovum,  its  greater  vascularity,  and  its  liability  to  sudden  great 
accumulations  of  blood.  The  fact  is  that  intramural  gestation  com- 
monly ends  in  rupture  of  its  sac. 

Cruveilhier,  with  that  sagacity  which  enabled  him  to  foreshadow  if 
not  to  forestall  so  many  discoveries  made  by  more  recent  writers,  care- 
fully pointed  out  the  distinction  between  these  cases  of  bilocular  uterus 
{uterus  cloisonne)  and  the  bifid  uterus,  and  especially  draM'S  attention 
to  pregnancy  in  these  uteri  in  comparison  with  cases  of  extra-uterine 
pregnancy- 
Gestation  may  take  place  in  one  half  of  an  equally  developed  two- 
horned  uterus.  In  this  case  things  usually  go  on  in  the  ordinary  way, 
and  labor  is  accomplished  as  in  a  normal  uterus.  Great  perplexity 
may,  however,  arise  during  pregnancy  and  labor  in  determining  the 
exact  seat  of  the  gestation.  If  the  vagina  is  double,  the  exploring 
finger  may  pass  up  the  empty  side,  and  fail  to  touch  the  ovum.  The 
same  accident  may  happen  when  the  septum  dividing  the  two  uteri  ex- 
tends to  the  roof  of  the  vagina.  Hemorrhagic  or  catarrhal  discharges 
may  take  place  from  the  empty  uterus,  which  may  be  erroneously  re- 
ferred to  the  pregnant  one.  Cruveilhier  figures  (Plate  v,  livraison  xiii) 
in  his  splendid  work,  a  double  uterus  removed  from  a  woman  who  died 
of  puerperal  fever.  A  septum  divides  the  body  from  fundus  to  cervix 
into  two  cavities.  Gestation  had  been  carried  on  to  term  in  one  side. 
The  empty  side  had  grown  to  keep  pace  with  the  pregnant  side. 

Gestation  may  proceed  to  term  in  a  one-horned  uterus,  as  in  the 
normal  uterus.  A  most  interesting  case  of  this  kind  is  recorded  in  the 
"  Philosophical  Transactions,"  1818.  A  woman  had  ten  ordinary 
labors,  and  died  after  labor  of  twins.  The  preparation  is  figured  by 
Granville.  The  right  side  of  the  uterus  only  was  developed  ;  the  left 
side  was  wanting ;  the  left  ovary  was  very  feebly  developed  ;  the  left 
kidney  was  absent.  Pokitansky  relates  two  cases,  and  Chiari  one  of 
a  similar  kind.  It  is  not  improbable,  however,  that  in  the  greater  num- 
ber of  instances  of  development  of  one-lialf  of  the  uterus  only,  there 
is  sterility,  whilst  in  others,  pregnancy  is  ended  by  abortion. 

Gestation  in  the  Rudimentary  Horn  of  a  One-horned  Uterus. 

But,  in  not  a  few  cases  the  horns  of  the  uterus  are  unequally  devel- 
oped. One  remains  rudimentary.  Pregnancy  may  take  place  in  either. 
When  it  takes  place  in  the  larger  horn,  which  represents  the  uterus 
proper,  all  may  proceed  as  in  the  ordinary  uterus.  But  it  will  be 
widely  diflPerent  if  the  rudimentary  horn  becomes  the  seat  of  gestation. 


ONE-HOENED    UTERINE.  391 

The  structure  of  this  part  is  not  adapted  to  accommodate  the  growing 
ovum. 

Kussmaul  has  subjected  this  form  of  gestation  to  minute  critical  and 
anatomical  analysis,  and  proves  that  it  has  often  been  mistaken  for 
tubal  gestation.  He  describes  in  detail  twelve  cases  of  this  kind.  The 
first  is  invested  with  unusual  interest.  It  is  taken  from  Dionis  (1G81). 
The  subject  was  a  lady  attached  to  the  court  of  Maria  Theresa,  who 
ordered  Dionis  to  perform  the  autopsy,  and  made  him  show  her  the 
preparation.  The  lady  died  under  signs  of  internal  rupture  when  pre- 
sumed to  be  five  months  pregnant.  Kussmaul  reproduces  the  figure 
given  by  Dionis.  It  represents  very  clearly  a  right-sided  uterus  un- 
impregnated,  and  a  rudimentary  left  horn  containing  the  fruit-sac, 
which  had  burst. 

Other  cases  which  Kussmaul's  analysis  restores  to  their  proper  sig- 
nificance are  taken  from  Canestrini,  Pfeffinger  and  Fritze,  Tiedemann 
and  Czihak,  Joerg  and  Giintz,  Drejer,  Ingleby,  Heyfelder,  Rokitansky, 
Scanzoni,  Behse,  Ramsbotham,  and  one  from  the  "Buffalo  Medical 
Journal,"  1846.  That  of  Luschka  is  the  one  I  select  for  illustration 
(see  Fig.  83,  p.  368).  Another  preparation  is  preserved  in  the  Pleidel- 
berg  Museum,  to  which  it  was  sent  by  Naegele.  A  woman,  aged 
thirty-six,  had  borne  four  healthy  children  after  easy  labors.  Preg- 
nant the  fifth  time,  she  suffered  none  of  the  symptoms  she  had  experi- 
enced in  former  pregnancies,  as  nausea,  vertigo,  and  so  on ;  when,  at 
the  end  of  the  fourteenth  week,  she  was  taken  suddenly  ill  Avith  acute 
pains  in  the  lower  abdomen,  collapse,  vomiting,  expulsive  efforts,  and 
died  in  seven  hours  and  a  half.  The  right  side  of  the  abdomen  was 
more  enlarged  than  the  left.  The  autopsy  revealed  a  large  quantity  of 
blood  in  the  abdomen;  in  the  midst  of  it  was  found  the  embryo  in  its 
envelopes,  and  liquor  amnii.  The  right  horn  of  the  uterus  was  the 
one  that  was  developed,  forming  a  uterus  unicornis  dexter ;  its  cavity 
was  lined  with  decidua ;  a  distinct  vaginal-portion  could  hardly  be  said 
to  exist.  From  the  left  side  of  this  right  uterus,  and  close  above  the 
cervix,  sprang  a  flat  thick  muscular  band  running  to  the  left  into  a 
pear-shaped  fruit-sac  as  big  as  a  goose's  egg.  From  the  under  circum- 
ference of  this  horn  sprang  close  together  the  left  round  ligament, 
and  the  left  Fallopian  tube  just  beneath  the  seat  of  rupture  of  the  sac. 
The  left  tube  was  quite  pervious  to  a  bristle  throughout  its  course  to  its 
point  of  entry  into  the  left  horn,  where  it  opened  funnel-w^ise.  It  was 
as  long  as  the  right  tube.  The  right  tube  was  also  pervious.  The 
muscular  wall  of  the  sac  was  almost  one  inch  thick  at  its  connection 
with  the  uterus,  but  became  much  thinner  near  the  seat  of  rupture. 
The  structure  of  the  sac  was  that  of  a  gravid  uterus.  Numerous  wide 
vessels  ran  through  the  muscular  wall,  increasing  in  number  and  size 
as  they  approached  the  inner  surface.  The  placenta  clothed  the  entire 
cavity.  The  cord  was  attached  near  the  rupture.  The  band  which 
joined  the  left  horn  with  the  right  one  was  muscular.  The  foetus  was 
well  formed,  female,  about  four  ounces  and  three-quarters  in  weight, 
shrunken,  and  for  the  most  part  deprived  of  epidermis. 

The  thirteen  cases  collected  by  Kussmaul  all  terminated  by  rupture 
of  the  fruit-sac  and  death.     The  period  of  rupture  varied  from  the 


392  ECTOPIC    GESTATION. 

fourth  to  the  sixth  month,  the  greater  number  bursting  in  the  fifth 
month.  One  case,  related  by  Rosen miiller,^  burst  at  the  end  of  five 
months.  It  thus  appears  that  the  rudimentary  horn  can  carry  on  ges- 
tation somewhat  longer  than  the  Fallopian  tube.  The  only  instance 
of  rupture  so  early  as  the  tenth  week  that  I  know  is  Luschka's,  referred 
to  at  p.  368.  It  is  remarkable  that  in  several  of  these  cases  the  sub- 
jects had  borne  children  at  term.  It  may  be  conjectured  that  the  de- 
veloped horn  of  the  uterus  was  the  seat  of  the  successful  gestations. 

Kussmaul  cites  in  detail  a  case  described  by  Fritze  (1779)  in  which 
gestation  was  carried  on  in  the  rudimentary  horn  of  a  uterus,  wdiich 
did  not,  as  is  usual,  end  by  bursting  of  the  fruit-sac.  The  embryo 
died  in  the  fifth  month  and  dried  up ;  the  fruit-sac  became  confounded 
with  the  embryonic  investments,  and  partly  calcified.  The  contents 
underwent  suppuration  after  thirty-one  years,  a  result  occasioned  prob- 
ably by  the  sharper  projections  of  the  bones  produced  by  the  progres- 
sive shrinking  of  the  foetus. 

It  is  remarked  as  a  curious  fact  that,  in  most  of  these  cases,  the  sac 
formed  in  the  rudimentary  horn  is  found  shut  oif  from  communication 
with  the  tube  on  the  one  side  and  with  the  uterus  proper  on  the  other. 
At  the  same  time  the  corpus  luteum  is  found  on  the  same  side  as  the 
gestation,  the  tube  being  pervious  until  it  approaches  the  sac.  The 
ovum  therefore  descended  along  its  proper  tube  into  the  rudimentary 
horn.  But  how  did  the  spermatozoa  get  to  it?  It  has  been  conjectured 
that  they  travelled  round  by  the  opposite  Fallo])ian  tube  through  the 
intervening  peritoneal  space,  and  in  at  the  abdominal  end  of  the  tube 
which  admitted  the  ovum.  I  think  it  more  likely  that  the  spermatozoa 
do  not  pursue  this  vagrant  circuitous  route.  At  the  time  of  impreg- 
nation I  believe  the  passage  from  the  developed  uterus  through  the 
rudimentary  horn  is  still  open,  permitting  the  meeting  of  the  two  ele- 
ments in  the  usual  way,  and  that  the  obliteration  of  the  openings  takes 
place  during  the  development  of  the  sac. 

There  is  confirmation  of  this  view  in  the  fact  that  in  one  case  the 
passage  was  found  pervious. 

The  accuracy  of  Ivussmaul's  interpretation  of  the  specimens  he  has 
examined  is,  I  think,  beyond  dispute.  He  proves  that  the  fruit-sac 
in  these  cases  is  formed  out  of  uterine  structure ;  that  the  Fallopian 
tube  has  no  share  in  it.  One  point  only  strikes  me  as  being  defectively 
described,  that  is,  the  constitution  of  the  placenta,  which  is  distinctly 
different  in  uterine  and  in  tubal  gestation.  In  the  first,  the  decidual 
element  is  characteristic;  whereas  in  the  latter,  it  is  often  scarcely  to 
be  distinguished.  In  future  investigations  this  test  should  not  escape 
attention. 

Virchow  supplies  another  test.^  A  woman  died  under  symptoms  of 
rupture.  The  preparation  was  at  first  taken  for  one  of  tubal  gestation, 
until  closer  analysis  was  made.  He  submitted  the  following  as  a  cri- 
terion between  tubal  gestation  and  gestation  in  a  rudimentary  horn. 
This  is  found  in  the  point  of  insertion  of  the  round  ligament.  In  the 
normal  uterus  this  lies  at  the  place  where  the  Fallopian  tube  opens 

1  Monats.<chrift  fiir  Geburtskiinde,  18G2.  «  ibid.,  18G0. 


ONE-HORNED     UTERINE.  393 

into  the  uterus.  Now,  if  an  ovum  becomes  developed  near  this  place, 
the  round  ligament  Avill  be  pushed  either  inwards  or  outwards ;  and 
thus  we  may  know  whether  we  have  to  deal  with  a  tubal  or  a  uterine 
gestation.  If  the  round  ligament  is  inserted  on  the  inner  side,  the 
new  cavity  must  be  regarded  as  the  tube  :  if  it  lie  on  the  outside,  the 
cavity  must  be  uterine  or  a  rudimentary  horn.  Tried  by  this  test,  it 
would  appear  that  two  cases  figured  by  Kussraaul,  as  gestation  in  a 
rudimentary  horn,  are  tubal  (Cases  IV  and  VIII).  But,  in  reality, 
the  gestation  may  have  begun  on  the  inside  of  the  insertion  of  the 
round  ligament,  and  in  course  of  development  have  proceeded  beyond 
this  point. 

The  investigations  of  Kussmaul  have  been  extended  by  the  minute 
and  accurate  researches  of  Professor  Turner.'  He  has  subjected  to  dis- 
section two  specimens  submitted  to  him  by  Sir  James  Simpson.  In 
both  of  these,  one  horn  was  in  a  rudimentary  condition,  but  impreg- 
nated. In  Case  I,  the  snbject  died  of  rupture  of  the  fruit-sac,  the 
foetus  having  reached  the  development  of  three  months.  The  wall  of 
the  left  cornu,  the  undeveloped  pregnant  one,  Avas  muscular,  like  that 
of  a  pregnant  uterus,  and  at  the  place  of  rupture  the  placenta  could 
be  seen  partially  adherent  to  its  inner  surface.  The  pedicle  was  exam- 
ined very  minutely  to  see  if  any  canal  connecting  the  cavity  of  the  im- 
pregnated horn  Avith  that  of  the  right  horn,  or  the  cervix  or  vagina, 
could  be  detected.  Although,  in  the  course  of  the  examination,  the 
muscular  fasciculi  of  which  the  pedicle  was  composed  were  dissected 
from  each  other,  no  orifice  at  either  of  the  extremities  of  the  pedicle 
could  be  detected.  In  Case  II,  it  was  also  the  left  horn  which  was 
rudimentary  and  pregnant.  The  foetus  was  retained  until  after  the  full 
period  of  utero-gestation.  The  subject  being  at  term,  and  in  "severe 
labor,"  sent  for  Dr.  Scott,  of  Dumfries.  The  os  uteri  was  low  down 
in  the  vagina,  and  the  uterus  was  found  of  a  natural  size  and  unim- 
pregnated.  There  was  an  enlargement  of  the  abdomen  extending  a  little 
to  the  left  side,  and  nearly  of  the  size  and  shape  of  a  uterus  containing 
a  foetus  at  term.  The  foetal  heart  was  heard.  The  pains  A¥ere  severe, 
and  complicated  with  convulsions.  The  pains  continued  for  several 
days,  and  then  she  began  to  go  about  as  usual.  She  died  six  months 
afterwards  of  phthisis.  Professor  Turner  found  a  sac  containing  a 
male  foetus.  One  side  of  the  sac  was  affixed  by  a  pedicle  to  the  cervix 
uteri ;  there  was  no  decidual  structure  in  the  right  cornu.  A  fine  probe 
could  be  passed  along  the  left  Fallopian  tube  up  to  the  wall  of  the  sac, 
but  its  inner  orifice  was  obstructed.  No  corpus  luteum  Avas  seen  in 
either  ovary.  No  communication  could  be  made  out  betAA^een  the  sac 
of  the  impregnated  cornu  and  the  canal  of  the  cervix. 

Tlie  real  character  of  the  gestation  in  these  cases  was  established  by 
the  following  tests :  "If  the  pregnancy  be  tubal,  the  round  ligament 
AAdll  be  found  attached  to  the  body  of  the  Avomb  on  the  inner  or  uterine 
side  of  the  dilated  sac  containing  the  embryo;  if,  on  the  other  hand, 
the  pregnancy  be  cornual,  then  the  point  of  attachment  of  the  round 
ligament  Avill  be  on  the  outer  side  of  the  dilated  foetal  sac.     In  both 

1  On  "  Malformations  of  the  Organs  of  Generation."     Edinburgh,  1866. 


394  ECTOPIC    GESTATION. 

specimens,  the  latter  relation  was  the  one  observed.  In  tubal  preg- 
nancies, the  length  of  the  Fallopian  tube  on  the  impregnated  side,  ex- 
ternal to  the  dilatation,  is  necessarily  less  than  that  of  the  entire  extent 
of  the  un impregnated  tube,  and  the  diminution  in  length  is  more 
strongly  marked  the  nearer  the  sac  lies  to  the  fimbriated  extremity. 
In  cornual  pregnancy,  on  the  other  hand,  no  diminution  in  the  length 
of  the  tube  on  the  impregnated  side  occurs — nay,  as  both  these  cases 
show,  the  tube  on  that  side  external  to  the  embryo-containing  sac,  may 
even  be  the  longer."  Turner  discusses  the  questions  arising  out  of  the 
impervious  condition  of  the  pedicle.  Had  this  existed  before  impreg- 
nation, or  had  a  canal  existed  in  the  unimpregnated  state  which,  dur- 
ing the  process  of  gestation,  had  become  obliterated  ?  Considering  that 
a  regular  gradation  had  been  traced  from  a  distinctly  recognizable  canal 
in  the  pedicle  to  that  condition  in  which  none  could  be  detected,  he  is 
disposed  to  think  that  the  pedicle  must  have  been  solid  before  impreg- 
nation was  effected.  Hence  the  mode  in  which  the  ovum  became  fer- 
tilized may  form  a  topic  for  further  discussion.  Turner  argues  in  favor 
of  the  travelling  of  the  semen  along  the  cornu  and  tube  of  the  more 
perfectly  developed  side  into  the  tube  of  the  rudimentary  cornu,  and 
then  into  the  cavity  of  the  latter. 

]Sj'oTE. — Dr.  Aveling  calls  my  attention  to  the  following  very  interesting  case  of 
hernial  gestation:  In  1706,  Gouey,  of  Eouen,  saw  a  young  lady  for  a  tumor  in  the 
right  groin.  It  grow  rapidly  and  without  pain,  and  there  was  felt  in  it  the  pulsa- 
tion of  an  artery."  At  the  end  of  two  months  and  a  half  the  tumor  was  as  large  as 
a  loaf  of  a  pound  weight.  He  laid  it  open,  and  found  a  hernial  protrusion  of  peri- 
toneum. Clear  fluid  escaped  when  this  sac  was  opened.  In  another  bag  inside  was 
a  foBtus  about  six  inches  long,  alive.  This  he  removed,  tying  the  cord.  Drawing 
very  gently  upon  the  cord,  the  placenta  came  away.  It  was  fastened  to  the  circum- 
ference of  the  musculus  obliquus  externus.  Gouey  conjectures  that  the  ovum 
impregnated  grew  to  the  round  ligament,  and  came  down  through  the  ring  in  the 
canal  of  Nuck,  and  then  grew  in  the  hernial  sac.  Dr.  Aveling  supposes  the  gesta- 
tion might  have  been  uterine;  and  that  it  was  an  inguinal  hernia  of  the  gravid 
uterus.— [From  Sloan,  MSS.,  4432,  No.  45.  "An  extract  from  5th  part  of  a  Book 
intituled  '  La  veritable  Chirurgie  etablie  sur  I'oxperience  &  la  raison,  par  le  Sieur 
Louis  Leger  de  Gouey.'  Printed  at  Koan,  1710,  in  8vo.,  containing  the  account  of 
a  foetus  cut  out  of  the  groin,  from  the  French  by  M.  D."] 


DEVELOPMENTAL,    FAULTS.  395 


CHAPTER   XXXVII. 

SPECIAL  PATHOLOGY  OF  THE  UTERUS  ;  ABNORMAL 
CONDITIONS;    DEVELOPMENTAL  FAULTS. 

Before  entering  upon  uterine  pathology  proper,  it  will  be  useful 
to  take  a  rapid  review  of  the  congenital  or  developmental  abnormali- 
ties of  the  uterus.  This  review  is  necessary,  because  these  abnormal 
conditions  are  often  attended  by  disorder  of  function,  and  give  rise  to 
symptoms,  the  interpretation  of  which  would  be  extremely  puzzling, 
if  not  sometimes  impossible,  unless  this  association  were  present  to  the 
mind.  Some  of  these  conditions  have  been  referred  to  in  the  history 
of  Retained  Menstruation,  and  of  Extra-uterine  Gestation.  The  fol- 
lowing summary  is  cliiefly  drawn  from  Rokitansky  and  Kussmaul, 
and  from  study  of  specimens  in  the  London  Museums.  The  principal 
varieties  of  atresia,  congenital  and  acquired,  have  been  considered  in 
the  Chapter  (XIX)  on  ''  Occult  Menstruation ;"  and  in  that  (Chapter 
XXXVI)  on  "Extra-uterine  Gestation,"  that  curious  form  of  uterus, 
resulting  from  arrested  development  of  one  horn,  has  been  sufficiently 
illustrated. 

Complete  absence  of  the  uterus  is  extremely  rare.  When  there  is 
apparent  absence  of  the  uterus  proper,  there  will  be  found  in  one  or 
both  sides,  behind  the  bladder,  in  the  peritoneal  fold  destined  to  receive 
the  internal  genital  organs,  one  or  two  small  flattened  roundish  bodies, 
solid,  made  out  of  uterine  substance,  and  with  a  cavity  lined  with  mu- 
cous membrane.  These  are  rudimentary  uterine  horns,  to  which  the 
Fallopian  tubes  have  a  distinct  relation,  although  sometimes  tliese  are 
absent,  and  sometimes  form  a  blind  worm-like  tube  closed  at  the  junc- 
ture with  the  rudimentary  uterus,  or  opening  into  it. 

This  uterine  development  in  the  form  of  two  oval  hollow  rudiments, 
from  which  a  Fallopian  tube  runs  outwards  to  its  ovary,  is  Mayer's 
uterus  hipartitus.  Inwards,  and  between  the  same  peritoneal  folds, 
these  uterine  rudiments  are  united  by  a  closed  cord  of  uterine  substance. 
At  the  seat  of  the  uterus  is  found  a  mass  of  connective  tissue  which, 
mingled  sparingly  with  the  just  mentioned  cord  of  uterine  fibres,  as- 
sumes the  outline  of  a  uterine  body,  and  is  inserted  below  into  the 
roof  of  the  vagina.     In  this  roof  a  stellate  scar  is  sometimes  seen. 

When  one  of  these  rudimentary  uteri  has  developed  into  a  uterine 
body,  then  there  appears  the  one-horned  uterus,  uterus  unicornis. 
When  both  are  developed,  then  we  have  the  two-horned  uterus,  uterus 
duplex. 

The  one-horned  uterus  always  appears  as  one  half  of  a  uterus,  that 
is,  as  the  unpaired  half  of  a  two-horned  uterus,  and  is  either  a  right 
or  a  left  uterus.  There  is  a  cylindrical  or  spindle-shaped  prominence 
on  the  corresponding  side  of  the  uterine  body,  from  the  upper  end  of 


396 


UTERUS. 


which  runs  the  tube.  Compared  with  the  normal  uterus,  the  one- 
horned  is  smaller ;  the  vaginal  portion  especially  is  smaller ;  in  the 
cervix  the  plicEe  palmatse  are  nearer  to  the  convex  border  of  the  uterus ; 
the  broad  ligament  on  the  side  of  the  missing  uterine  half  is  larger, 
often  of  extraordinary  size. 

The  uterine  rudiment  of  the  other  side  presents  all  the  above  con- 
ditions :  it  is  a  solid  or  a  hollow  little  body ;  it  sometimes  lies  at  a 
considerable  distance  from  the  one-horned  uterus  in  a  wide-spreading 
peritoneal  fold  ;  and  sometimes  it  is  altogether  wanting.  The  corre- 
sponding ovary  and  tube  follow  the  same  rule.  The  junction  between 
the  rudimental  and  the  one-horned  uterus  presents  the  greatest  diver- 
sities. At  times  there  is  none.  At  times  there  runs  from  the  rudi- 
ment a  round  or  flat-round  cord,  composed  of  uterine  parenchyma,  in 
an  oblique  direction  towards  the  one-horned  uterus,  and  inserts  itself 
into  or  above  the  internal  orifice,  sometimes  higher,  sometimes  lower. 
This  cord  is  solid,  or  contains  a  canal  which  connects  the  cavity  of  the 
one-horned  uterus  with  that  of  the  rudimental  uterus,  and  makes  this 
last  susceptible  of  impregnation.  But  we  have  seen,  especially  from 
Professor  Turner's  researches,  that  impregnation  possibly  takes  place 
even  where  the  structure  uniting  the  rudimentary  horn  with  the  de- 
veloped horn  is  solid.     (See  Chapter  XXXVI.) 

Here  it  may  be  useful  to  place  the  following  figure  taken  from  Tiede- 
mann  (Fig.  85).  It  is  described  as  a  "  uterus  strongly  developed  to  the 
right,  the  neighborhood  of  the  isthmus  atrophied."  It  is  probably  an 
instance  of  imperfect  development  of  the  left  horn  of  the  uterus.  In 
such  cases  it  is  probable  that  the  general  development  of  the  uterus  is 


Fig.  85. 


Uterus  strongly  developed  to  right.    Probably  imperfect  development  of  left  side. 
(From  Tiedemann.) 

also  defective.  I  introduce  it  because  I  believe  it  represents  a  formation 
which  is  not  very  infrequent.  I  have  many  times  met  with  cases  in 
which  the  uterus  resembled  this  one  in  size  and  jjosition,  there  being  a 
small  OS  uteri  scarcely  projecting  into  the  vagina.  They  have  been 
brought  under  observation  on  account  of  dysmenorrhoea,  amenorrhoea, 
or  sterility. 

When,  as  already  said,  the  two  rudiments  constituting  tlie  uterus 
bipartitus  are  developed  equally  after  the  type  of  the  one-horned  uterus, 


DEVELOPMENTAL    FAULTS. 


397 


there  appears  an  excess  of  development  in  the  shape  of  tico  uterine 
halves,  which  are  fused  together  from  one  point  of  their  convex  borders 
in  the  form  of  a  uterus  bicornis.  The  degree  of  tAvo-hornedness  varies, 
and  is  determined  by  the  spot  from  which  the  two  uterine  halves  run 
together.  The  lower  this  is,  the  more  obtuse  is  the  angle  of  union,  and 
so  much  the  greater  is  the  divergence  of  the  two  halves.  It  falls  very 
rarely  below  the  orijiciwn  internum,  and  here  the  two  run  into  one  com- 
mon cervix  in  such  a  manner  that  they  lie  horizontally.  The  higher 
the  place  of  union,  the  more  acute  is  the  angle,  so  that  at  last  the  two- 
hornedness  is  nothing  more  than  an  unusual  divergence  of  the  two 
horns  of  the  uterus,  which  exhibits  outwardly  a  somewhat  broader 
fundus,  but  is  otherwise  normal.  Under  these  conditions  there  appears 
between  the  two  uterine  halves  a  uterine  mass  which  has  the  sio-nifi- 
cance  of  a  fundus  uteri.  The  higher  this  connecting  bond  between 
the  uterine  halves  is,  the  more  prominent  is  this  significance;  and  when 
it  is  on  a  level  with  the  ends  of  the  uterine  horns,  and  overtops  these 
with  its  arch,  then  the  two-hornedness  has  vanished. 

This  is  illustrated  in  Fig.  86,  taken  from  a  girl  who  died  of  phthisis 


Fig. 


Double  or  bicornute  uterus,  with  a  single  cervix  and  os  uteri. 
(From  nature,  from  a  specimen  in  Guy's  Museum,  2261''*.) 


at  the  age  of  seventeen.  She  was  well  developed.  The  Graafian  vesi- 
cles were  numerous  and  large.  The  vagina  was  well  formed.  The 
horns  open  into  a  common  uterine  cavity.     The  walls  are  unusually 


398 


UTERUS. 


thick;    the  fundus,  although  depressed  in  the  centre,  indicating  the 
original  two-hornedness,  is  straighter  than  in  Figs.  87,  88. 

The  bicornute  uterus  is  illustrated  in  a  remarkable  specimen  in  the 
Royal  College  of  Surgeons,  taken  from  a  mulatto  (Physiological  Series, 
2828).     In  this  specimen  the  body  of  the  uterus  is  drawn  out  into  two 


Fig.  87. 


Bicornute  uterus. 
(Royal  College  of  Surgeons,  ad  nat.) 


long  horns,  so  that  the  line  representing  the  fundus  between  the  two 
horns  is  a  long  concave  arch.  More  commonly  the  two  horns  continue 
parted  for  an  indeterminate  space  by  a  septum  descending  from  the 
fundus  to  a  variable  length.  It  may  reach  as  low  as  the  os  uteri  inter- 
num, or  even  the  os  externum.  If  the  septum  is  incomplete,  it  ends 
below  in  a  sharp  edge,  but  it  commonly  stretches  lower  down  along  the 
posterior  wall,  in  the  form  of  a  ridge,  like  a  raplie. 

In  Fig.  88,  also  taken  from  a  specimen  in  Guy's  Museum,  No. 
2261^°,  is  seen  a  double  uterus,  with  a  single  cervix,  so  that  only  one  os 
uteri  opens  into  the  single  vagina.  Such  a  case  might  be  recognized  in 
the  living,  by  feeling  the  indented  fundus,  as  well  as  by  the  sound, 
which  might  perchance  enter  the  two  cavities  one  after  the  other. 

In  other  cases  the  division  extends  along  the  cervical  portion,  so  that 
two  ora  uteri  open  into  one  common  vagina.  Such  a  case  may  be  very 
puzzling  in  labor,  as  I  once  experienced.  I  was  called  in  consultation 
to  a  case  of  puerj^eral  convulsions,  in  order  to  deliver  the  -woman. 
The  surgeon  in  attendance,  using  his  right  hand,  always  touched  the 
child's  head  presenting  at  the  os  uteri.  I,  as  is  my  custom,  examining 
with  the  left  hand,  could  only  feel  the  head  through  a  thick  solid  wall 


DEVELOPMENTAL    FAULTS. 


399 


of  flesh.  It  was  not  until  I  followed  exactly  the  clue  indicated  by  my 
friend  that  I  touched  the  head,  and  could  apply  instruments.  There 
was  a  double  uterus.     My  finger  had  first  entered  the  empty  side. 


Bicornute  uterus,  the  septum  dividing  the  uterine  cavity  into  two,  descends  as  far  as  the  isthmus. 
(From  nature,  from  a  specimen  in  Guy's  Museum.) 


In  Cruveilhier's  magnificent  work  is  a  beautiful  drawing  of  a  double 
uterus,  taken  from  a  woman  who  died  of  puerperal  fever.  The  uterus 
which  contained  the  foetus  presents  much  the  same  appearance  as  is 
usual  after  delivery,  in  the  single  uterus.  The  other  uterus  is  en- 
larged in  sympathy  with  its  impregnated  fellow,  but  is  considerably 
smaller. 

In  a  few  very  important  cases  there  is  atresia  of  one-half  of  the 
uterus  bicornis. 

To  the  two-hornedness,  with  formation  of  a  septum,  belongs  the 
uterus  hilocidaris,  which  consists  in  the  septum-formation  in  a  uterus, 
normal  as  regards  the  degree  of  divergence  of  its  horns.  The  septum 
in  the  uterus  bilocularis  presents  all  the  variations  seen  in  the  uterus 
unicornis.  Its  presence  is  often  signified  by  a  greater  breadth  of  the 
uterine  body,  and  sometimes  by  a  shallow  furrow  along  its  posterior 
wall. 

The  vagina  presents  corresponding  diversities  in  the  uterus  bicornis 
and  the  bilocularis.  It  is  normal,  or  there  is  a  septum,  dividing  the 
canal  more  or  less  completely  into  two. 

The  septum  may  extend  all  along  the  uterus  and  vagina.  The  patho- 
logical relations  of  this  form  of  uterus  have  been  referred  to  in  the 
Chapter  on  "  Occult  Menstruation."     The  condition  is  not,  I  believe, 


400 


TJTEEUS. 


very  uncommon.  Most  museums  can  show  a  specimen;  and  every 
now  and  then  a  living  specimen  comes  under  notice,  either  accidentally 
or  on  account  of  some  difficulty  in  the  functions  of  menstruation  or 
labor.  But  these  difficulties  are  by  no  means  necessary.  Things  may 
go  on  very  well,  one  vagina  and  one  uterus  acting.  Figs.  89,  90, 
are  taken  from  a  preparation  (2261^'^)  in  Guy's  Museum.  There  is 
one  equally  typical  in  St.  Thomas's.  The  Guy's  specimen  was  taken 
from  a  woman  aged  50,  who  died  of  influenza;  she  had  been  married 


Fig. 


Double  uterus  and  vagina. 

«,  w.  The  right  and  left  uterine  cavities,  communicating  by  separate  cervical 

canal  and  os  into  v  v,  right  and  left  vaginae. 

a.  The  septum  of  dense  fibrous  tissue,  which  runs  along  the  median  line. 

(From  nature,  from  a  specimen  in  Guy's  Museum.) 


twenty  years,  remaining  sterile.  The  tubes  and  ovaries  were  matted 
together  by  adhesions.  The  body  of  the  uterus  seen  'externally  was 
single,  only  a  slight  depression  marking  the  internal  division. 

As.  regards  menstruation,  conception,  and  labor,  the  described  forms 
of  uterus  behave  as  follows :  The  constituent  rudiments  of  the  uterus 
bipartitus  are  capable  of  conception;  an  accumulation  of  menstrual 
blood  in  the  cavity  of  such  a  rudiment  with  dilatation  of  it  may  hap- 
pen. Where  such  a  rudiment  is  connected  with  a  one-horned  uterus  by 
a  perforated  bond  of  union,  it  is  capable  of  conception,  and  so  even 
when  it  is  solid.  The  gestation  terminates,  as  in  tubal  gestation,  by 
rupture,  within  three  or  four  months.  The  uterus  unicornis  and  the 
uterus  bicornis,  as  well  as  the  bilocularis,  are  capable  of  conception.  In 
the  two  last,  repeated  gestations  occur  interchangeably ;  sometimes  in 
one,  sometimes  in  the  other  uterine  half.     When  conception  takes  place 


DEVELOPMENTAL,    FAULTS. 


401 


in  one  half,  a  decidua  is  formed  in  the  other  half,  and  grows  during 
the  early  part  of  the  pregnancy  equally  with  the  pregnant  half.  More- 
over, twin-pregnancy  may  occur,  not  only  in  one  uterine  half,  but  preg- 


Fk;.  90. 


Transverse  section  of  the  vagiute  of  the  same  specimen  as  the  preceding  figure,  showing  v,  v,  the 
separate  vaginal  canals.    (Nat.  size.) 


nancy  has  been  observed  in  the  two  halves  simultaneously.     In  this 
case  one  foetus  is  usually  arrested  in  development. 

In  these  uterine  forms  the  ruptures,  abortions,  tedious  labors  ob- 
served are  accounted  for  by  the  smaller  mass  of  the  uterus,  and  by  the 
diminution  of  the  uterine  fundus. 

AVhen  there  is  atresia  of  one-half  of  the  uterus  bicornis,  retention  of 
menstruation,  with  its  perilous  consequences,  will  occur.  Rokitansky 
relates  a  case  where  the  fluid  retained  in  the  closed  half  caused  perfor- 
ation of  the  septum,  and  discharge  into  the  half  which  communicated 
with  the  vao-ina. 

Abnormal  size  of  the  uterus  may  originate  in  foetal  life  or  may  arise 
later,  from  premature  sexual  maturity.  It  consists  in  hypertrophy  and 
dilatation. 

Hypertrophy  affects  the  whole  uterus  or  only  a  part  of  it.  As  par- 
tial hypertrophy,  that  of  the  vaginal-portion  is  especially  deserving  of 
attention. 

General  hypertrophy  is  commonly  so  formed  that  the  uterine  cavity 
is  uniformly  enlarged  [excentric  hypertrophy).  In  lesser  degrees  the 
cavity  is  often  normal,  and  often  it  is  narrowed  [simple  and  concentrio 
hypertrophy).  The  enlargement  attains  in  the  first  form  considerable 
degrees,  becoming  as  large  as  a  goose's  egg,  or  a  fist,  and  larger;  its 
walls  becoming  half  an  inch  or  an  inch  thick.  The  most  important 
enlargement  occurs  with  connective-tissue  tumors  which  prolapse  into 
the  cavity  or  grow  in  it.  A  simultaneous  elongation  occurs  in  hyper- 
trophy of  the  prolapsed  uterus.  The  hypertrophied  uterine  mass  is 
often  like  that  of  the  normal  uterus,  and  often  the  connective  tissue  in 
it  is  increased,  and  thus  its  consistency  is  greater. 

Dilatation  of  the  uterine  cavity  is  commonly  attended  by  thickening 

m 


402  UTEEUS. 

of  its  walls  {active  dilatation) ;  and  often  with  thinning  (passive  dilata- 
tion). It  is  generally  produced  by  accumulations  within,  the  result  of 
stenosis  or  atresia  at  a  lower  point.  In  Guy^s  Museum  (2261")  is  a 
specimen  showing  dilatation  of  the  body  of  the  uterus  with  thinning 
of  its  walls.  A  quantity  of  albuminous  matter  had  collected  within  it, 
and  the  os  internum  was  closed. 

Abnormal  smallness  of  the  uterus  may  be  the  consequence  of  defective 
development.  The  uterus  is  small  from  retaining  its  infantile  form,  or 
its  growth  was  arrested.  In  the  latter  case  it  is  small  throughout, 
thin-walled,  its  mucous  membrane  is  thin,  its  plicse  palmatse  very 
slightly  raised.  Commonly  the  other  organs,  the  whole  body,  are  re- 
tarded in  development,  and  especially  the  heart  is  small. 

The  smallness  may  be  due  to  atrophy.  This  may  affect  the  whole 
uterus,  or  simply  the  cervix,  or  the  vaginal-portion. 

Atrophy  of  the  whole  uterus  follows  chiefly  upon  chronic  catarrh  in 
advancing  age;  often  prematurely  upon  cessation  of  menstruation ;  and 
sometimes  even  in  younger  persons,  in  consequence  of  the  rapid  succes- 
sion of  labors.  Mostly,  the  uterine  cavity  is  narrowed  (concentric 
atrophy),  and  here  and  there,  in  the  cavity,  or  at  the  orifices,  there  are 
adhesions  of  mucous  membrane.  Often,  the  uterine  cavity  is  enlarged 
by  the  accumulation  of  secretions.  When  these  adhesions  exist  (ex- 
centric  atrophy)  the  uterine  substance  is  dense,  tenacious ;  or  especially 
in  advanced  age,  softened,  pale,  penetrated  by  rigid,  widened,  calcified 
arteries,  a  condition  which  disposes  to  bleedings.  (See  Fig.  91.)  Fibrous 
tumors  also  lead  to  atrophy  of  the  uterus. 

Atrophy  of  the  cervix  is  commonly  caused  by  the  dragging  which  it 
undergoes  from  the  rising  of  uterine  and  ovarian  tumors  into  the  ab- 
domen. It  is  drawn  out  lengthwise,  made  thinner ;  the  duplicature  of 
the  vagina  which  surrounds  the  vaginal-portion  is  unfolded,  and  the 
vag-inal  roof  is  transformed  into  a  cone.  Then  closures  of  the  cervical 
canal  ensue,  and  even  at  times  a  gradual  separation  of  connection. 

Atrophy  of  the  vaginal-portion  occurs  sometimes  after  repeated  labor. 

Mr.  Walter  Whitehead  relates'  a  remarkable  case  in  which  it  seems 
probable  that  the  uterus  and  ovaries  completely  disappeared  after  labor. 

A  woman,  aged  39,  first  menstruated  at  11,  married  at  25,  had  four 
children  within  three  years  and  a  half,  the  first  two  being  born  prema- 
turely. Severe  flooding  took  place  after  the  last  labor.  She  had  a  long 
convalescence,  but  there  was  no  history  of  acute  disease.  During  eleven 
years  menstruation  never  returned,  nor  was  there  the  slightest  leucor- 
rhoea  ;  she  had  become  quite  indifferent  to  sexual  intercourse.  For  four 
months  previous  to  birth  of  last  child  she  had  passed  large  quantities 
of  blood  per  anum.  She  was  a  tall,  pale,  thin  woman,  with  markedly 
flabby  cheeks,  and  a  commencing  arcus  senilis ;  the  mammse  shrunken 
and  flat,  with  apparent  atrophy  of  gland-structure.  No  cervix  or  uterus 
could  be  detected ;  but  a  small  triangular  oj)ening  was  felt  and  seen  in 
the  position  of  the  os.  A  No.  12  elastic  catheter  passed,  without  any 
pressure,  eight  inches  through  the  opening.  Every  mode  of  examina- 
tion failed  to  detect  a  uterus.     The  sound  passed  through  the  opening 

>  British  Med.  Journ.,  Oct.,  1872. 


ATROPHY. 


403 


could  be  felt  under  the  abdominal  wall,  two  inches  above  the  umbilicus. 
It  might  be  conjectured  that  the  sound  went  through  the  fundus  of  the 
uterus ;  but  repeated  examinations,  varied  in  manner,  by  Dr.  Thor- 
burn,  Dr.  Lloyd  Roberts,  and  Mr.,  Windsor,  corroborated  the  conclusion 
drawn  by  Mr.  Whitehead. 

The  following  drawing  (Fig.  91)  taken  from  Carswell's  "Morbid 


Fig.  91. 


Atrophy  of  the  uterus  ami  ovaries  from  ossification  of  the  arteries     After  Carswell. 
a,  a.  Uterus  laid  open  :  b,  b,  tubes  ;  c,  c,  ovaries  ;  d,  d,  d,  the  principal  arteries,  and  several  of  their 
smaller  branches  completely  ossified  and  nearly  impervious  ;  the  substance  of  the   uterus  e,  contain- 
ing a  multitude  of  small  arteries  in  the  same  state  ;  a  tumor/,  composed  of  dilated  veins  and  cellulo- 
fibrous  tissue,  occupying  the  fundus  of  the  uterus. 


Anatomy,"  represents  a  form  of  atrophy  of  the  uterus  connected  with 
calcification  of  the  ovario-uterine  arteries. 

Some  forms  of  atresia  and  stenosis  have  been  described  in  Chapter 
XIX. 

Obliteration  of  the  uterine  cavity  is  sometimes  the  result  of  concentric 
atrophy  ;  it  often  results  from  adhesions  following  accumulations  of 
mucus,  mucous  polypi,  or  connective-tissue  tumors. 

Obliteration  of  the  cervix  uteri  and  of  the  orifices  is  commonly  caused 
by  closure  from  pullulating  ovula  Nabothi.  More  often  the  os  inter- 
num is  closed  by  flexions.  Occasionally  it  is  the  result  of  longitudinal 
dragging  of  the  cervix.  The  os  internum  may  be  closed  by  cicatrices 
from  lacerations  and  bruisings,  from  ulcerative  loss  of  substance,  from 
amputation  of  the  vaginal-portion,  from  the  action  of  cauteries.  In 
aged  women,  it  not  unfrequently  closes  by  a  process  of  concentric 
atrophy,  the  margin  of  the  ring  of  the  os  uteri  getting  glued  up  by 
dense  epithelial  scales  resembling  a  membrane. 


404 


UTERUS. 


Fig.  92,  from  a  specimen  in  the  London  Hospital,  put  up  by  me, 
represents  closure  at  three  different  points  of  the  uterine  canal. 


Fig.  92. . 


London  Hospital,  Ea.  56,  from  nat.  size  (Dr.  Barnes), 
stenosis ;  atresia ;  dilatation  of  uterus. 


This  uterus  came  from  a  woman  aged  43,  married,  barren.  It  is 
divided  imperfectly  into  three  cavities.  The  upper  two,  a,  b,  are  hour- 
glass shaped ;  the  lowest,  c,  about  three-quarters  of  an  inch  long,  is 
separated  from  the  middle  one  by  a  nearly  complete  fold  of  mucous 
membrane.  In  the  middle  cavity,  the  uterus  is  deeply  furrowed,  and 
studded  with  large  gaping  follicles.  The  atresia  was  no  doubt  due  to 
endometritis  with  follicular  inflammation. 

Abnormities  of  Shwpe  of  the  Uterus. — As  a  congenital  anomaly,  there 
occurs  the  congenital  obliquity  in  connection  with  the  uterus  bipartitus, 
unicornis,  bicornis,  and  bilocularis.  Tlie  most  marked  form  of  this 
is  seen  when  one  horn  with  its  tube  stands  higher  than  the  other,  and 
the  vaginal  portion  is  correspondingly  oblique.  This  uterus  lies  ob- 
liquely in  the  pelvis,  inclining  to  one  or  other  side  of  tlie  vaginal  roof. 
(See  Fig.  85  from  Tiedemann.)  The  broad  ligament  of  this  side  is 
narrower,  and  the  ovary  lies  nearer  to  the  uterus.  Sometimes  this 
uterus  is  bent  in  an  angular  form  on  that  side  which  is  highest.  Often 
the  higher  side  is  more  dense  and  bigger. 

There  are  asymmetrical  forms  of  the  uterus  caused  by  excessive  de- 


UTERINE    PATHOLOGY.  405 

velopment  of  one  half  of  the  body  of  the  uterus.     When  there  is 
bending  on  this  side,  the  retort  form  is  produced. 

Among  acquired  malformations,  there  is  obliquity  from  one-sided 
dragging  of  a  fibrous  tumor,  or  an  ovarian  tumor,  from  dragging  in 
hypertrophy  of  the  vaginal-portion,  from  scars,  from  various  accumu- 
lations in  its  cavity,  and  from  inflammatory  adhesions  in  one  broad 
ligament. 


CHAPTER  XXXVIII. 

GENERAL    OBSERVATIONS    ON    UTERINE    PATHOLOGY;    EFFECTS 
OP    LABOR   AND   LACTATION;    INVOLUTION    IN   DEFECT  AND 

EXCESS. 

In  studying  the  pathology  of  the  uterus,  it  is  especially  necessary  to 
keep  in  constant  view  the  peculiarities  of  structure  and  the  physiology 
of  the  organ.  No  organ  in  the  body  undergoes  such  remarkable 
jjhysiological  changes.  At  each  menstrual  period  there  is  increased 
vascularity,  increased  volume,  increased  muscular  energy,  the  develop- 
ment of  new  tissue,  followed  by  a  retrograde  process  of  involution, 
which  effects  the  return  to  the  ordinary  state.  At  every  pregnancy 
the  changes  wrought  are  more  wonderful  still.  Under  its  physiologi- 
cal influences,  the  uterus  is  thus  continually  subject  to  alternate  hyper- 
trophy and  atrophy,  or  more  strictly  speaking,  involution.  The 
mucous  membrane  is  endowed  wdth  extraordinary  regenerative  power. 
And  these  active  reproductive  and  solvent  forces  inherent  in  the  uterus 
are  constantly  ready  to  be  called  into  action  on  any  abnormal  stimulus. 
Thus,  if  a  fibroid  tumor  form  in  the  uterine  wall,  or  project  into  its 
cavity,  the  vessels  and  tissues  respond  just  as  they  do  to  the  stimulus 
of  impregnation. 

Interruptions,  then,  to  the  fulfilment  of  the  organic  changes  evoked 
by  function  will  account  for  a  large  proportion  of  the  cases  of  uterine 
disease,  especially  congestion,  engorgement,  hyperplasia,  hypertrophy, 
atrophy.  Continually  recurring  functional  acts  will  also  exert  an  in- 
fluence, generally  injurious,  sometimes  beneficial,  upon  morbid  con- 
ditions. 

Perhaps  there  is  no  organ  in  the  body  so  prone  to  hypertrophy  as 
the  uterus.  Its  functional  hypertrophy  has  often  been  likened  to  in- 
flammation, notably  that  hypertrophy  of  the  mucous  membrane  which 
results  in  the  formation  of  the  decidua. 

The  diatheses  also  must  not  be  overlooked.  "When  one  of  these 
exists,  it  may  be  the  primary  cause  of  the  development  of  disease  in 


406  UTERINE    PATHOLOGY. 

the  uterus ;  or,  if  one  of  them  happen  to  complicate  uterine  disease 
which  has  arisen  from  other  causes,  it  will  impress  its  stamp,  will 
greatly  increase  the  difficulty  of  cure,  and  will,  therefore,  dictate  largely 
the  course  of  treatment.  The  strumous,  dartrous  or  herpetic,  rheu- 
matic or  gouty  diatheses,  or  the  syphilitic,  tuberculous,  or  cancerous 
cachexiee  often  play  a  most  important  part  in  the  production,  continu- 
ance, and  curability  of  uterine  diseases. 

The  uterus  is  liable  to  alteration  of  structure  and  disturbance  of 
function  from  causes  external  to  itself.  Some  of  these  may  take  their 
rise  in  distant  organs,  some  in  neighboring  organs ;  and  the  uterus,  as 
an  integral  part  of  the  whole  organism,  is  subject  to  the  constitutional 
disorders  which  affect  the  body,  and  to  the  disorders  ensuing  upon  the 
multitudinous  varieties  of  toxaemia.  Thus  the  uterus  is  liable  to  tu- 
bercle. The  blood  dyscrasiae  which  dispose  to  hemorrhages  from  the 
mucous  membranes  are  perhaps  more  likely  to  induce  hemorrhage  from- 
the  uterus  than  from  other  organs.  This  is  especially  true  during  the 
period  of  sexual  activity.  Thus  scurvy,  small-pox,  measles  often 
cause  uterine  and  tubal  hemorrhages. 

Certain  medicinal  substances  or  poisons  circulating  in  the  blood  act 
with  special  intensity  upon  the  uterus. 

The  uterus  is  remarkably  susceptible  to  nervous  impressions,  emo- 
tional, reflex,  and  so-called  sympathetic ;  and  through  these  nervous 
impressions  it  is  certain  that  functional  and  even  structural  disturb- 
ances are  produced.  The  uterus  stands  in  the  most  intimate  correla- 
tion with  the  ovaries  and  breasts.  With  the  ovaries  it  is  directly 
associated  by  its  vascular  supply,  which  may  be  said  to  be  common 
to  both  organs.  The  vessels  supplying  botli  so  freely  anastomose  that 
it  is  impossible  for  hyperemia  to  exist  in  the  one  without  involving 
the  other  in  a  similar  condition.  This  is  most  strikingly  manifested 
in  the  uterine  hypersemia  evoked  by  the  ovarian  menstrual  nisus ;  but 
it  is  almost  equally  clear  that  what  is  called  ovarian  dysmenorrhoea 
reacts  ujjon  the  uterus  also. 

The  application  of  the  suckling  infant  to  the  breast  often  causes  con- 
traction of  the  uterus.  I  have  often  known  it  cause  uterine  hemor- 
rhage. Many  women  are  conscious  of  pain  in  the  uterus  when  suckling. 
The  application  of  leeches  or  blisters  to  the  breast  has  brought  on 
menstruation. 

Obstinate  pruritus  pudendorum,  by  keeping  up  a  constant  excess  of 
blood  and  local  nervous  disorder,  not  seldom  brings  about  a  congestion, 
enlargement,  or  infarctus  of  the  uterus. 

The  uterus  in  its  turn  is  the  starting-point  for  manifold  affections  of 
the  distant  organs,  and  of  the  general  system.  I  do  not  in  this  work 
more  than  glance  at  the  influences  which  the  pregnant  womb  exerts. 
Those  which  spring  from  the  non-pregnant  womb  are  scarcely  less 
striking. 

The  uterus  is  especially  liable  to  change  of  structure  and  disturbance 
of  function  under  the  influence  of  changes  affecting  its  neighboring 
organs.  Floating,  as  it  docs  freely,  between  the  bladder  and  the  rec- 
tum, it  is  subject  to  constant  change  of  position,  according  to  the  vary- 
ing conditions  of  fulness  or  emptiness  of  these  organs.     Of  course,  so 


EFFECTS  'of    LABOR    AND    LACTATION.  407 

long  as  these  conditions  are  within  physiological  limits,  the  uterus 
adapts  itself  readily  to  them  ;  but  if  the  natural  mobility  of  the  uterus 
be  impeded,  as  by  plastic  deposits  about  the  broad  ligaments,  by  blood- 
masses  and  plastic  deposits  in  the  retro-uterine  pouch,  by  tubal  ges- 
tation, or  by  any  body  becoming  attached  to  it,  uterine  hypersemia 
proceeding  to  infarctus  or  hypertrophy  is  sure  to  follow.  In  every 
case  of  pelvic  peritonitis,  or  so-called  pelvic  cellulitis,  the  uterine  walls 
are  found  thickened.  This  is  a  frequent  cause  of  secondary  puerperal 
hemorrhage,  and  of  hemorrhage  continuing  for  months  after  labor  as 
menorrhagia.  This,  it  may  be  said,  is  due  to  arrested  involution  from 
the  state  of  pregnancy,  this  form  of  inflammation  commonly  arising 
after  labor  or  abortion.  But  I  believe  this  is  only  one  particular 
instance  of  a  general  law.  The  same  state  of  engorgement  and  hyper- 
plasia is  observed,  no  matter  Mdiat  the  cause  which  fixes  the  uterus. 
This  fixing  and  the  attendant  changes  in  the  circulation  of  the  organ 
account  in  great  part  for  the  enlargement  of  the  body  of  the  uterus, 
which  takes  place  when  cancer  invades  the  neck.  If  inflammation 
begin  in  the  broad  ligament,  or  in  Douglas's  pouch,  not  spreading  to 
the  uterus,  but  fixing  it  by  external  deposits,  enlargement  equally 
follows. 

The  uterus  also,  I  have  observed,  is  liable  to  hyperplastic  enlarge- 
ment, as  the  result  of  oft-repeated  or  long-continuous  hypersemia  pro- 
duced by  disorder  of  the  liver,  kidneys,  or  heart. 

We  shall  find  the  history  of  the  natural  changes  ensuing  upon  men- 
struation, pregnancy,  and  labor  to  be  a  necessary  introduction  to  the 
right  appreciation  of  engorgement,  inflammation,  hypertrophy,  pro- 
lapsus, versions  and  flexions  of  the  uterus,  and  of  other  uterine  and 
peri-uterine  afifections.  This  history,  then,  which  really  includes  the 
study  of  the  etiological  relations  of  so  many  disorders,  will  here  be 
briefly  traced. 

Effects,  Local  and  Constitutional,  of  Labor  and  Lactation. 

A  very  large  projDortion  of  the  cases  of  uterine  disease  which  come 
under  treatment  are  the  result,  more  or  less  immediate,  of  parturition. 
To  understand  this  aright  it  is  necessary  to  study  Avhat  are  the  effects 
of  parturition  upon  the  uterus.  Parturition  is  a  violent  process.  Even 
in  ordinary  labor  the  dilatation  of  the  cervix  uteri  is  effected  in  great 
part  by  the  direct  pressure  of  the  head  or  other  part  of  the  child.  In 
many  cases  the  pressure  thus  exerted  amounts  to  severe  bruising,  con- 
tusion of  tissue,  attended  by  a  partial  sliding,  a  glacier-like  movement 
of  the  mucous  membrane,  away  from  the  subjacent  tissues.  This  trau- 
matic process  necessarily  involves  the  rupture  of  many  small  vessels, 
producing  ecchymosis  and  serous  effusion  in  the  connective  tissue,  and 
even  in  the  wall  of  the  cervix.  That  the  edge  of  the  os  externum 
uteri  is  almost  constantly  torn  in  first  labors  is  notorious. 

Lmpeded  Involution. — The  first  in  time,  if  not  in  importance  of  the 
results  of  labor,  is  the  persisting  enlargement  of  the  uterus,  which  marks 
the  failure  of  the  process  of  involution.  Within  a  month  the  uterus 
ought  to  complete  its  return  to  the  ordinary  state ;  that  is,  it  ought  to 


408  IMPEDED    INVOLUTION. 

recover  from  a  bulk  represented  by  one  and  a  half  pounds  weight  or 
more  to  two  or  three  ounces.  This  wonderful  change  is  brought  about 
chiefly  by  two  processes.  The  first  is  one  of  active  and  tonic  contrac- 
tion of  the  muscular  fibre,  which,  by  diminishing  the  bulk  of  the  organ, 
squeezes  out  of  its  vessels  all  superfluous  blood.  The  second  process  is 
a  compound  one  of  absorption  and  excretion.  The  now  useless  solid 
tissue  is  first  converted  into  granular  fat,  then  absorbed  into  the  circu- 
lation, and  lastly  ejected  from  the  organism  by  the  glandular  apparatus. 
Both  these  processes  are  liable  to  be  impeded.  The  first  and  most  essen- 
tial act,  that  of  vigorous  and  persistent  muscular  contraction,  is  often 
badly  performed.  A  degree  of  hsemostasis  remains,  which  keeps  up 
congestion,  disposing  to  hemorrhage  and  inflammation.  The  excessive 
bulk  and  weight  of  the  organ  occasion  local  distress.  This  condition, 
moreover,  retards  the  second  essential  process  of  absorption.  And  if  to 
this  be  added,  as  is  too  commonly  the  case,  feeble  glandular  action  and 
weak  nutrition,  involution  is  seriously  retarded. 

Besides  mere  want  of  power,  other  causes  may  concur  in  frustrating 
the  due  involution  of  the  uterus  and  vagina;  and  these  it  is  desirable 
to  enumerate.  Associated  under  the  general  terra,  want  of  power,  we 
of  course  include  the  influence  of  accidentally  complicating  diseases,  as 
fevers,  phthisis,  and  of  the  cachexise,  as  struma  and  syphilis.  Under 
the  influence  of  these  diseases  involution  rarely  goes  on  well.  A  marked 
excess  of  bulk,  with  chronic  endometritis,  may  be  observed  for  weeks 
and  months.  Flooding  during  and  after  labor,  by  weakening  general 
power,  and  especially  by  impairing  tonicity  of  muscular  fibre,  retards 
involution.  The  occurrence  of  perimetric  inflammation  during  child- 
bed, especially  if  attended  by  effusions  which  impede  the  mobility  of 
the  uterus,  surely  retards  involution.  Indeed,  I  think  it  may  be  laid 
down  as  an  aphorism  that  whenever  the  mobility  of  the  uterus  is 
arrested,  whether  the  cause  be  external  or  internal,  a  degree  of  hyper- 
plasia is  the  result.  Thus,  as  in  the  case  just  mentioned  of  perimetritic 
adhesions,  imperfect  involution  and  a  process  of  slow  infarction  follow. 
In  the  case  of  extra-uterine  gestation,  where  the  foetal  sac  comes  into 
adhesion  with  the  uterus,  the  primary  development  of  the  uterus  under 
the  stimulus  of  conception  is  maintained,  and  even  exaggerated.  When 
peritonitis  and  adhesions  form  from  maligant  disease,  the  uterus  is 
always  increased  in  bulk,  and  this  increase  is  greatly  due  to  this  cause, 
not  alone  to  the  direct  influence  of  the  malignant  disease. 

The  inevitable  injury  inflicted  upon  the  cervix,  and  especially  upon 
the  vaginal-])ortion,  may  evoke  such  an  active  process  for  repair  that 
general  involution  may  be  impeded. 

Displacements  of  the  uterus  also  impede  involution ;  and  displace- 
ments are  very  apt  to  occur  after  labor.  The  most  common  displace- 
ments are  retroversion,  retroflexion,  and  prolapsus.  When  one  of 
these  occurs  the  free  circulation  through  the  uterine  vessels  is  neces- 
sarily interrupted.  The  arteries  may  pump  in  blood,  but  the  return  by 
the  veins  is  obstructed  by  the  tortuous  course  and  angulations  produced 
by  the  displacement.  Hsemostasis,  frequent  metrorrhagia,  arrest  of 
involution,  and  continuous  infarction  are  the  result. 

Fibroid   tumors,  or    polypi    in   the   uterus,  retard    involution,   by 


IMPEDED    INVOLUTION. 


409 


keeping  up  a  developmental  attraction  of  blood.  It  is  a  kind  of  spuri- 
ous gestation. 

I  am  disposed  to  fix  the  normal  period  required  for  complete  invo- 
lution as  one  month.  But  this  applies  to  persons  in  health,  and  placed 
in  favorable  circumstances.  Hospital  air  is  an  unfavorable  condition ; 
and  I  am  told  that  in  the  lying-in  hospitals  abroad  six  weeks  is  the 
time  usually  required. 

The  reduction  in  size  which  the  uterus  has  to  undergo,  and  the  brief 
space  within  which  this  change  has  to  be  effected,  constitute  one  of 
the  most  striking  facts  in  physiology.  At  the  full  term  of  pregnancy 
the  cavity  of  the  uterus,  says  Simpson,  contains  above  400  cubic 
inches;  and  in  the  non-pregnant  it  can  hardly  be  said  to  be  equal  to 
one  cubic  inch.  Yet  to  this  latter  capacity  the  uterus  must  be  reduced 
in  a  month. 

The  extent  of  involution  of  the  uterus  after  labor  may  be  accurately 
traced,  by  observation,  by  touch,  and  by  measurement  with  the  sound. 
The  following  diagram  (Fig.  93),  from  Simpson,  gives  an  idea  of  the 


Fig.  93. 


The  outer  outline  represents  the  bulk  of  the  uterus  arrested  in  its  involution  after  pregnancy, 
inner  one  represents  the  bulk  it  ought  to  attain.    (After  Simpson.) 


The 


ordinary  difference  in  bulk  of  the  uterus  in  which  involution  has  been 
arrested,  and  that  of  the  uterus  in  its  ordinary  state. 

Dr.  Snow  Beck  showed  to  the  London  Medical  Society  (1851)  a 


410  IMPERFECT    INVOLUTION. 

specimen  of  arrested  involution,  under  the  title  "  A  New  Disease  of 
Uterus."  The  structure  of  the  hypertrophied  uterus  showed  no  in- 
flammatory or  heterologous  deposits;  but  the  tissue  of  the  organ  was 
similar  in  its  histological  characters  to  the  tissue  of  the  uterus  at  the 
ninth  month  of  pregnancy,  except  only  that  its  component  fibres 
were  smaller  in  size. 

The  evidence  of  the  traumatic  injury  sustained  in  labor  remains  in 
the  indented  cicatrices  round  the  margin  of  the  os,  which  are  char- 
acteristic of  the  vaginal-portion  in  women  who  have  borne  children. 
But  if  the  parts  be  examined  soon  after  labor,  much  more  striking 
marks  of  the  injury  they  have  sustained  will  be  witnessed.  Imme- 
diately after  labor  the  vaginal-portion  is  large,  flabby,  pulpy,  so  as  to 
be  almost  indistinguishable  to  the  touch.  It  is  some  days  before  it  re- 
tracts to  any  considerable  extent,  or  regains  much  firmness  of  texture. 
The  tissue  of  the  cervix  and  of  the  connective  tissue  surrounding  the 
vessels  at  their  entry  from  the  broad  ligaments  is  infiltrated  with 
serum,  which  has  to  be  absorbed.  The  entire  thickness  of  the  vaginal- 
portion,  as  I  have  repeatedly  seen  in  post-mortem  examinations,  at  the 
end  of  a  week  or  even  ten  days  after  labor,  is  still  soft,  large,  and 
black  from  ecchymosis. 

It  must  also  be  remembered  that  the  vagina  during  pregnancy  and 
labor  undergoes  changes  analogous  to  those  which  affect*  the  uterus. 
During  pregnancy  the  extreme  vascularity  of  the  vagina  gives  a  char- 
acteristic test  of  this  condition.  Its  walls  grow  in  length  and  breadth ; 
its  tissues  become  softer,  and  more  distensible.  To  the  touch  this  is 
veiy  perceptible.  During  labor  it  is  subjected  to  enormous  distension, 
and  even  violence.  Involution  will  be  arrested  under  the  same  condi- 
tions as  those  which  arrest  involution  of  the  uterus.  The  vagina  then 
remains  larger  and  looser;  folds  may  even  project  through  the  vulva. 
Thus  we  get  a  heavier  uterus,  which  has  to  be  supported  by  a  vagina 
of  less  than  usual  power. 

Under  favorable  circumstances,  the  process  of  repair  is  rapid  and 
complete.  But  in  a  great  number  of  instances,  the  conditions  are  not 
favorable.  Repair  is  retarded  by  a  weakly  state  of  the  constitution,  by 
the  intercurrence  of  various  morbid  actions,  by  imprudence  in  getting 
about  too  soon,  and  the  too  early  resumption  of  ordinary  duties.  I  am 
persuaded  that  rest,  'physical  and  physiological,  for  at  least  a  month  after 
labor,  is  essential  to  complete  the  repair  of  the  injuries  sustained,  and 
the  involution  of  the  pelvic  organs.  This  proposition  will,  perhaps, 
appear  overstrained  in  the  opinion  of  those  ^\'ho  advocate  a  generous 
diet  from  the  day  of  labor,  and  removal  to  the  drawing-room  in  less 
than  a  week.  I  have  so  frequently  seen  pernicious  effects,  immediate 
and  remote  from  this  practice,  that  I  cannot  hesitate  to  condemn  it.  It 
is  easy  to  adduce  any  number  of  cases  of  women  who  have  been  thus 
treated,  and  have  made  good  recoveries.  But  the  practice  is  not  thus 
justified,  if  the  exceptions  also  are  numerous.  It  is  true,  that  many 
women  return  to  their  ordinary  mode  of  life  within  a  fortnight,  and 
continue  with  more  or  less  success  to  perform  their  duties.  But  the 
frequent  penalty  is  uterine  and  constitutional  disease.  The  speed  and 
completeness  of  recovery  from  labor  depend  also  greatly  upon  the 


CAUSES.  411 

health  and  physical  power  of  the  individual.  Women  accustomed  to 
hard  work,  hard  living,  and  exposure  to  the  weather,  complete  the  pro- 
cess of  repair  much  more  quickly  than  those  who  are  nursed  in  luxury, 
and  whose  first  experience  of  hard  work  is  acquired  in  the  task  of 
bringing  forth  a  child.  In  the  first  class  of  women,  the  muscular,  vas- 
cular, and  glandular  systems  are  in  vigorous  working  order.  Effete 
matter  is  quickly  got  rid  of.  Every  organ  soon  returns  to  its  wonted 
state.  In  delicate  and  pampered  w^oraen,  on  the  contrary,  the  muscular 
fibre  is  lax,  the  glandular  organs,  especially  those  of  the  skin,  are  im- 
perfectly developed,  they  do  their  duty  feebly,  and  are  easily  over- 
powered when  an  unusual  strain  is  thrown  upon  them.  The  nervous 
system  is  stimulated  beyond  measure,  and  acquires  predominance  over 
the  rest.  Under  these  conditions  it  is  not  surprising  that  the  extra- 
ordinary revolution  in  the  system,  and  the  im]3ortant  local  changes 
which  have  to  be  effected  after  labor,  are  accomplished  with  difficulty, 
imperfectly,  and  are  the  point  of  departure  for  various  constitutional 
and  local  morbid  processes. 

Neglect  of  the  due  period  of  "  rest "  for  repair  is  especially  apt  to 
retard  the  restoration  of  that  part  of  the  uterus  to  which  the  placenta 
adhered.  The  changes  that  have  to  be  effected  here  are  more  extensive 
than  in  the  rest  of  the  internal  surface.  It  is  no  uncommon  thing  to  see 
in  women  dying,  a  month  and  more  after  labor,  a  rough  area,  marking 
the  site  of  the  placenta.  This  is  often  covered  with  a  muco-purulent 
secretion,  showing  that  the  return  to  the  ordinary  condition  is  not  com- 
pleted. It  is  easy  to  understand  that  to  tax  the  uterus  in  this  condition 
with  the  premature  resumption  of  functional  work,  will  start  endometri- 
tis, which  will  readily  assume  a  chronic,  and  even  permanent  character. 

Analogous  conditions  follow  abortion,  although  the  actual  violence 
inflicted  upon  the  cervix  is  not  so  important  an  element.  Abortion 
.also  differs  from  labor  at  term  in  this  respect:  the  development  of  the 
uterus  is  brought  to  a  sudden  termination  prematurely ;  that  is,  before 
the  tissues  and  the  system  have  attained  the  conditions  favorable  to 
rapid  and  complete  involution.  Within  the  first  three  or  four  months, 
for  example,  the  muscular  contractibility  of  the  uterus — a  prime  agent 
in  starting  healthy  involution — is  not  nearly  so  effective  as  at  term; 
and,  in  addition  to  this,  the  transformation  of  the  mucous  membrane 
into  decidua,  is  arrested  at  a  stage  when  the  adhesion  to  the  uterus  is 
much  more  intimate,  more  vascular,  and  embraces  a  relatively  much 
larger  area.  Its  separation  is  a  far  more  violent  process ;  and  if,  as  is 
not  unlikely,  the  mucous  membrane  was  unhealthy  before  conception, 
its  separation  will  be  apt  to  leave  a  subacute  endometritis,  with  un- 
healthy new  mucous  membrane. 

Rest  is  as  essential  after  abortion  as  after  labor.  The  indifference 
with  which  many  women  in  every  rank  regard  "a  slight  miscarriage," 
is  a  source  of  much  future  trouble.  A  miscarriage  is  looked  upon  as 
slight  in  proportion  to  the  earliness  in  pregnancy  at  which  it  occurs. 
But  it  is  a  grave  error  to  measure  in  this  way  the  importance  of  an 
abortion.  The  earliest  abortion  may  entail  consequences  far  from 
slight,  if  due  hygienic  precautions  are  not  observed. 

Now,  one  of  the  surest  means  of  inducing  some  one  or  more  of  the 


412  IMPERFECT    INVOLUTIOJSr. 

foregoing  involution-retarding  conditions,  is  premature  exchange  of 
"rest"  for  exertion.  The  upright  posture  within  the  first  week  or 
fortnight  will  surely  increase  the  local  vascular  tension,  and  promote 
disiDlacement  of  the  uterus.  To  add  the  influence  of  gravity,  and  of 
increased  hydraulic  pressure  in  the  vessels  whilst  the  uterus  is  still  of 
inordinate  weight,  and  its  supports  are  disabled,  cannot  fail  to  be  injuri- 
ous. The  most  healthy  stimulus  to  uterine  involution  is  the  natural 
function  of  lactation.  If  this  duty — this  physiological  complement  to 
parturition — be  neglected,  involution  will  not  go  on  smoothly.  The 
application  of  the  infant  to  the  breast  causes  contraction  of  the  organ. 
It  is  injurious  to  lose  this.  Lactation,  moreover,  causing  a  derivation 
of  physiological  activity  to  a  distant  organ,  tends  to  promote  rest  in  the 
pelvis.  Indeed,  one  of  the  beneficent  purposes  of  this  alternative  or 
cyclical  action  of  the  generative  organs,  is  to  give  each  in  its  turn  the 
rest  that  is  necessary  for  restoration.  This  natural  order  cannot  be 
broken  with  impunity.  The  penalty,  or  rather  one  of  the  penalties  of 
suppressing  the  function  of  the  breasts,  by  depriving  the  uterus  and 
ovaries  of  their  allotted  respite,  is  the  resumption  of  work  before  they 
have  had  time  or  opjjortunity  to  recover  their  fitness  for  the  task. 

It  is  to  this  evil  that  women  of  the  easier  classes  are  more  especially 
exposed.  The  increasing  neglect  of  the  function  of  lactation  is,  I  be- 
lieve, a  prolific  cause  of  uterine  disease.  This  neglect  does  not,  how- 
ever, entirely  arise  from  indifference  to  maternal  duties,  or  the  fancied 
more  imperative  duties  of  social  life.  The  inability  to  suckle  is,  in 
numerous  cases,  real.  The  system,  the  breasts  want  the  power,  the 
capacity,  to  secrete  milk.  After  honest  endeavors,  it  is  too  often  found 
that  after  a  few  weeks  of  scanty  secretion  and  painful  suckling,  the 
child  and  mother  alike  show  evidence  of  the  futility  of  the  effort. 
Nothing  can  lend  stronger  confirmation  to  the  theory  I  have  expressed, 
as  to  the  relative  unfitness  of  women  nursed  in  luxuiy  to  carry  out  in 
its  completeness  the  function  of  reproduction,  than  this  failure  of  the 
breasts.  The  breasts  are  glandular  organs  developed  out  of  the  skin. 
They  are  closely  analogous  in  structure  to  the  sebaceous  glands  of  the 
skin.  Their  activity  and  degree  of  development  may  be  taken  as  a 
measure  of  the  activity  of  the  skin  and  other  glandular  organs.  All 
show  the  same  kind  and  degree  of  incapacity.  Unless  the  general 
system  have  been  duly  exercised  and  called  into  activity  by  the  whole 
course  of  life,  the  glandular  system,  like  the  rest,  will  remain  imper- 
fectly developed.  It  is  unreasonable  to  exj)ect  the  breasts  to  become 
all  at  once  competent  to  their  work. 

On  the  other  hand,  there  frequently  occur  amongst  the  working 
classes  and  others,  cases  where  involution  of  the  uterus  is  arrested  by 
lactation.  This  is  because  lactation  is  a  task  that  exceeds  the  strength. 
Deficient  food,  bad  health,  and  hard  work  combine  to  exhaust  the 
struggling  mother.  The  process  of  repair  is  arrested,  and  a  chronic 
endometritis,  with  engorgement,  abrasion  of  epithelium  from  the  os 
uteri,  and  leucorrhoea,  sometimes  tinged  M'ith  blood,  or  even  alternating 
with  metrorrhagia,  always  more  or  less  prolapsus  or  retroversion,  result. 
The  worn,  thin,  pallid  aspect  of  the  subject  attests  exhaustion.  The 
pulse  is  small,  accelerated ;  nutrition  is  feeble ;  the  muscles  are  flal^by ; 


CAUSES.  413 

at  one  point  muscular  debility  is  invariably  marked,  the  dorsal  muscles, 
especially  between  the  scapulae,  are  always  painfully  aching ;  they  are 
in  fact  overstrained  by  the  heavy  burden  of  carrying  the  child.  The 
nervous  system  in  many  ways  suffers  from  imperfect  nutrition  ;  vertigo, 
syncope,  are  the  sure  signs  of  anaemia,  and  show  how  the  brain  is 
starved ;  dimness  of  sight,  musc£e  volitantes,  every  degree  of  amaurosis 
commonly  attend. 

Mr.  Jonathan  Hutchinson  has  investigated  this  subject  with  a 
sagacity  pointed  by  an  unsurpassed  range  of  pathological  knowledge. 
He  rightly  says  that  dimness  of  vision  during  suckling  may  be  merely 
an  indication  of  the  existence  of  hypermetropia,  and  does  not  neces- 
sarily indicate  retinal  disease.  Until  weakened  by  lactation,  many 
hypermetropic  women  experience  no  inconvenience,  being  able  to  bear 
the  accommodative  strain  necessary  to  overcome  the  error  of  refraction  ; 
but  during  lactation  they  find  it  difficult  to  keep  the  ciliary  muscle  up 
to  its  unusual  exertion.  He  says  it  is'  well  to  examine  if  spectacles 
are  not  requisite. 

Any  nervous  affection  to  which  the  subject  retains  a  predisposition, 
from  antecedent  attacks,  or  from  hereditary  transmission,  is  now  ex- 
tremely apt  to  break  out.  Thus,  overlactatiou  induces  a  recurrence 
of  epilepsy,  chorea,  hysteria,  ague :  affections  from  which  the  subject 
might  otherwise  have  been  freed. 

Another  jjoint  of  suffering  is  the  lower  lumbar  and  sacral  region. 
This  is  partly  the  indication  of  reflex  distress,  proceeding  from  the 
diseased  uterus,  partly  of  pressure  of  the  enlarged  organ  on  the  pelvic 
nerves,  and  partly  of  spinal  exhaustion  from  the  constant  wear  and 
tear  occasioned  by  the  irritation  of  a  diseased  organ  acting  upon  an 
imperfectly  nourished  nervous  centre. 

These  subjects  will  also  frequently  complain  of  pain  referred  to  the 
seat  of  one  or  other  ovary,  most  frequently  the  left.  This  Dr.  Henry 
Bennet  has  long  insisted  upon  as  characteristic  of  irritation  jiropagated 
from  the  inflamed  cervix.  It  may,  according  to  him,  and  I  am  dis- 
posed to  agree  with  him,  be  regarded  as  a  consensual  pain.  Others, 
however,  regard  it  as  an  indication  of  actual  ovarian  inflammation. 

The  period  when  overlactatiou  may  be  said  to  have  begun  cannot 
be  fixed.  It  is  determined  by  the  relative  strength  of  the  individual. 
Whilst  it  may  be  said  that  few  women  are  able  greatly  to  transgress 
the  normal  period  of  nine  or  ten  months  with  impunity,  it  is  certain 
that  many  show  all  the  signs  of  overlactatiou  much  earlier  than  this. 
We  must,  then,  look  to  the  symptoms,  and  not  to  the  time  the  patient 
has  been  suckling. 

In  a  considerable  proportion  of  cases,  the  functions  of  the  ovary 
cannot  be  suppressed  beyond  a  few  months,  if  at  all.  It  is  in  vain 
that  the  attempt  is  made  to  keep  ovulation,  with  its  consequences — 
menstruation  and  pregnancy — in  abeyance  by  taxing  the  breast.  The 
ovary  is  the  dominant  organ,  and  sooner  or  later  will  assert  its  suprem- 
acy. Accordingly,  we  often  find  one  of  two  things  taking  place  in 
the  course  of  lactation.  First,  menstruation  returns,  sometimes  in  a 
few  months  after  labor,  and  generally  within  a  year,  except,  indeed, 
phthisis  or  other  exhausting  disease  intervene,  or  premature  atrophy 


414  OVERLACTATIOX. 

of  the  ovaries  and  uterus  be  induced ;  or,  secondly,  unless  a  new  preg- 
nancy occur.  This  may,  or  may  not,  be  preceded  by  a  menstrual  ap- 
pearance. Some  women  "  never  see  anything  from  one  pregnancy  to 
another."  Whilst  suckling,  they  fall  pregnant,  without  exactly  know- 
ing when.  The  position  of  a  woman  in  this  predicament  is  indeed 
trying.  She  is  laboring  to  support  three  beings  at  the  same  time. 
She  is  goading  into  simultaneous  work  the  breasts  and  the  uterus, 
which  ought  to  relieve  each  other.  No  wonder  if,  under  this  double 
outrage  to  nature,  her  own  strength  break  down,  and  if  the  welfare 
of  the  child  at  the  breast,  and  the  existence  of  the  embryo  in  the 
womb,  be  equally  imperilled.  Accordingly,  we  often  observe  that 
abortion  occurs  under  these  circumstances.  This  accident  is  the  com- 
bined result  of  the  degradation  of  the  mother's  blood,  which  becomes 
unfitted  to  carry  on  the  nutrition  of  the  embryo  and  of  the  structures 
which  bring  it  into  relation  with  the  mother ;  of  the  reflex  irritation 
constantly  starting  from  the  breast,  and  promoting  congestions  and 
contractions  in  the  womb ;  and  of  displacement,  such  as  prolapsus  or 
retroversion  and  chronic  metritis. 

The  condition  of  the  uterus  after  the  exhaustion  of  overlactation  is 
usuall}"  characteristic.  Its  bulk  is  somewhat  excessive;  its  canal  is 
patulous,  easily  admitting  the  sound;  the  cavity  of  the  body  is  a  little 
dilated,  so  that  its  walls  are  not  in  apposition,  as  in  the  healthy  uterus ; 
the  appearance  of  the  vaginal-portion  is  peculiar:  its  aspect  is  pallid, 
partaking  of  the  general  anaemia,  its  lips  are  swollen  out  in  lobes  sepa- 
rated by  the  scars  resulting  from  the  slight  rents  which  were  produced 
during  labor;  to  the  feel  and  sight  the  tumid  os  is  flabby,  soft,  as  if 
oedematous;  all  round  the  os,  and  some  way  inside  the  cervical  cavity, 
the  epithelium  is  often  abraded ;  tenacious  viscous  mucus  fills  the  canal ; 
the  sound  always  causes  a  little  oozing  of  blood;  and  metrorrhagia  is 
usual.  Such  is  a  common  condition.  Sometimes  there  is  great  con- 
gestion and  appearance  of  vascularity.  The  abraded  portions  present 
little  granulating  elevations,  secreting  a  semi-opaque  mucus.  The  mar- 
gin of  the  abrasion  is  well  defined;  Avhere  the  structure  retains  its  epi- 
thelium investment  the  color  is  bluish  or  purple.  This  color  becomes 
much  deeper  if  pregnancy  has  supervened. 

Although  ready  to  sink  from  physical  exhaustion,  the  mother  still 
clings  to  the  burden  which  is  dragging  her  to  the  ground.  It  often 
requires  the  most  decisive  authority  the  physician  can  exert  to_  induce 
these  poor  women  to  give  up  the  unequal  struggle.  The  most  effective 
argument  often  is  to  point  to  the  child,  which  is  generally  pale,  thin, 
deficient  in  the  firmness  of  healthy  nutrition.  We  may  thus  more 
easily  persuade  the  mother  to  give  up  a  course  which,  whilst  surely 
sapping  her  own  health,  is  doing  her  child  no  good. 

To  wean,  then,  is  generally  the  first  injunction.  The  other  indica- 
tions are  to  restore  the  general  health,  to  improve  nutrition,  to  bring 
back  the  proper  proportion  of  red-globules  to  the  blood,  and  at  the 
same  time  to  cure  the  local  disease. 

In  these  cases  quinine  and  iron  are  of  inestimable  value ;  strychnine 
is  of  scarcely  less.  They  almost  take  rank  as  food.  The  doses  should 
not  be  large,  especially  at  first.     One,  or  at  most  two,  grains  of  quinine 


OVERLACTATION.  415 

two  or  three  times  a  daj^,  and  one-thirtieth  of  a  grain  of  strychnine  is 
enough.  More  will  not  be  tolerated  if  the  exhaustion  is  great.  Qui- 
nine has  a  special  beneficial  action  beyond  that  as  a  general  tonic.  It 
has  a  distinct  property  in  causing  contraction  of  the  uterine  fibre.  In 
this  way  it  promotes  involution,  the  diminution  of  congestion,  and  the 
tendency  to  metrorrhagia.  To  produce  this  action,  larger  doses  are 
useful.  Strychnine  possesses  a  similar  property  in  a  marked  degree. 
That  the  diet  should  be  as  generous  as  can  be  digested,  it  is  needless  to 
sav.  Alcohol  should  form  a  moderate,  strictly  limited  ingredient. 
The  light  wines  of  France,  the  Khine,  and  Hungary  are  the  best  stimu- 
lants and  aids  to  digestion.  But  where  it  can  be  digested,  good  stout 
or  ale  to  the  extent  of  a  pint  or  two  pints  daily  is  to  be  preferred.  Cod- 
liver  oil  is  often  of  great  use.  Under  this  regimen,  the  blood  is  speedily 
enriched  in  quality,  and  the  eifect  is  seen  in  returning  strength,  in  im- 
proved nutrition,  and  more  vigorous  performance  of  all  the  functions. 
We  shall  thus  have  gained  one  necessary  condition  for  the  repair  of 
local  mischief  Without  this  improved  constitutional  power,  mere 
local  treatment  would  probably  fail. 

The  local  treatment  required  is  generally  simple.  One  condition  is 
rest.  This  is  partly  attained  by  keeping  the  prolapsed  uterus  at  its 
proper  level  by  means  of  a  Hodge's  pessary.  This  brings  singular  aid 
also  by  relieving  the  local  hypersemia,  by  facilitating  the  return  of 
blood  from  the  uterus.  Once  every  four  or  five  days  the  abraded  sur- 
face of  the  vaginal-portion  and  the  interior  surface  of  the  cervix  uteri 
should  be  lightly  touched  with  solid  nitrate  of  silver.  Or  a  stick  of 
three  grains  of  sulphate  of  zinc  may  be  introduced  every  third  or  fourth 
day  into  the  cervix.  A  vaginal  injection  of  oal^:  bark,  tannin,  or  sul- 
phate of  zinc,  or  alum,  should  be  used  daily  or  even  twice  a  day.  The 
cold  douche,  if  it  can  be  borne  without  pain,  is  often  useful.  In  sum- 
mer the  cold  hip-bath  may  be  employed. 

Under  this  treatment  the  abraded  surface  will  commonly  heal  over, 
the  congestion  disappearing,  the  bulk  of  the  cervix  becomes  reduced, 
the  tendency  to  prolapsus  is  lessened  by  this  diminished  weight  of  the 
organ,  and  by  the  recovered  tonicity  of  the  vagina  and  other  uterine 
supports.  If  at  this  time,  when  all  active  inflammation  has  ceased, 
any  marked  degree  of  enlargement  of  the  vaginal-portion  and  bearing 
down  remain,  we  find  a  useful  remedy  in  the  potassa  cum  calce  or 
Vienna  paste.  This  should  be  rubbed  gently  across  the  most  enlarged 
lip  of  the  OS  uteri,  so  as  to  produce  a  small  eschar.  This  sets  up  a 
moderate  degree  of  local  irritation  which  stimulates  to  healthy  granu- 
lation, and  excites  absorption.  The  raw  surface  will  cicatrize  within  a 
week  or  ten  days,  and  the  bulk  of  the  vaginal-portion  will  commonly 
be  reduced. 

This  treatment,  although  limited  to  the  vaginal-portion  and  the  canal 
of  the  cervix,  exerts  a  beneficial  action  upon  the  enlarged  body  of  the 
uterus.  It  is  certain  that  the  congested,  inflamed  state  of  the  vaginal- 
portion  keeps  up  a  similar  condition  of  the  whole  organ ;  and  it  is  also 
a  matter  of  experience  that  remedies  applied  to  the  vaginal-portion  act 
not  only  by  removing  the  irritation  of  contiguous  disease,  but  also  by 
derivation.     The  eschar,  for  example,  set  up  by  potassa  cum  calce  upon 


416  INFLAMMATION    OF    THE    BREASTS. 

the  OS  uteri,  acts  by  derivation  upon  the  body  as  a  bh'ster  does  upon 
internal  organs. 

To  set  invohition  going,  when  the  case  is  acute,  Simpson  recommends 
local  antiphlogistics.  This  treatment  is  especially  indicated  where  any 
trace  of  inflammation  remains.  ■  But  in  cases  where  all  inflammatory 
action  seems  to  have  died  out,  he  says,  a  local  antiphlogistic  course  has 
the  effect  of  setting  up  absorption  in  the  enlarged  organ.  If  the  patient 
is  not  very  weak,  he  advises  the  application  of  a  dozen  leeches  to  the 
vaginal-portion  of  the  uterus  or  to  the  perineum. 

In  these  more  acute  cases,  and  in  all  the  more  chronic  cases,  he  in- 
sisted on  the  use  of  counter-irritants.  Antimonial  or  croton  ointments, 
or  the  cantharides  blister  applied  to  the  hypogastric  region,  or  painting 
this  region  with  tincture  of  iodine  until  it  produced  vesication,  were 
amongst  his  remedies.  At  the  same  time  he  kept  the  vaginal-portion 
of  the  cervix  uteri  immersed  in  ointments  of  mercury  or  iodide  of  lead, 
or  bromide  of  potassium  introduced  as  vaginal  pessaries. 

As  internal  remedies  he  relied  upon  iodide  and  bromide  of  potassium. 

Scanzoni  recommends  the  introduction  into  the  vagina  every  night 
of  a  sponge  saturated  with  a  solution  of  iodide  of  potassium  in  glycerin, 
in  the  proportion  of  one  in  eight,  or  of  an  ointment  consisting  of  five 
grains  of  iodo-chloride  of  mercury  in  an  ounce  of  lard. 

I  have  found  the  iodine  and  glycerin  decidedly  useful.  The  patient 
may  apply  it  herself  by  the  aid  of  my  speculum.     (Fig.  46,  p.  131.) 

Dr.  Grustavus  Murray  recommends  the  use  of  the  galvanic  pessary. 

I  have  also  seen  reason  to  think  favorably  of  the  use  of  the  bromo- 
iodic  waters  of  the  Woodhall  Spa. 

One  is  frequently  asked  "  How  long  will  it  take  to  get  well  ?"  To 
this  the  physician  can  give  no  definite  answer,  unless  all  the  conditions 
of  cure  be  placed  fairly  within  his  control.  Whilst  the  patient  is  pur- 
suing more  or  less  actively  her  usual  course  of  life,  and  the  treatment 
is  often  interrupted,  the  disease  may  linger  for  any  length  of  time. 
But  take  her  into  hospital,  where  all  the  necessary  measures,  negative 
and  positive,  hygienic  and  medical,  are  systematically  carried  out,  and 
a  cure  within  two  or  three  months  may  with  confidence  be  predicted. 

Closely  associated  with  this  subject  is  that  of  inflammatory  engorge- 
ment and  abscess  of  the  breast.  This  condition  is  commonly  the  result 
of,  and  bears  evidence  to,  constitutional  debility,  and  unfitness  of  the 
breast  for  its  function.  It  occurs  at  two  distinct  periods.  The  most 
common  is  at  the  onset  of  the  attempt  to  suckle.  The  other  period  is 
after  lactation  has  been  kept  up  for  some  months.  Strumous  women, 
who  are  especially  liable  to  glandular  and  connective-tissue  engorge- 
ments, are  particularly  liable  to  early  abscess  of  the  breast.  The  con- 
stitution and  the  organ  at  once  rebel.  If  the  attempt  to  force  them  be 
persisted  in,  phlegmons  and  abscesses  are  sure  to  form.  It  is  not  within 
the  scope  of  this  work  to  discuss  the  physiology  and  pathology  of  preg- 
nancy and  chiklbed.  I  refer  to  lactation  only  in  reference  to  our  pres- 
ent subject.  Much  as,  both  in  the  interest  of  mother  and  child,  it  is 
desirable  to  suckle,  it  is  better,  where  the  function  is  not  likely  to  be 
successfully  carried  on,  not  to  make  the  attempt.  It  is  rare  for  abscess 
to  form  where  no  attempt  to  suckle  has  been  made.     The  constitutional 


SUPEEINVOLUTION    OF     UTERUS.  417 

conditions  which  contraindicate  lactation  are  general  debility,  ansemia, 
a  strumous  diathesis ;  the  local  conditions  are,  depressed,  undeveloped, 
excoriated  nipples,  or  evidence  of  phlegmons  in  the  breasts.  These 
conditions,  and  others,  lead  to  retention  of  milk.  The  secreted  milk. 
clogs  the  milk-ducts,  and  this  condition  leads  to  stasis,  and  inflamma- 
tion in  the  capillary  network  surrounding  the  acini.  When  it  has  been 
determined  to  abandon  lactation,  it  is  a  common  practice  to  apply  bel- 
ladoinia  to  the  breasts  under  the  belief  that  this  drug  possesses  the 
property  of  drying  up  the  milk.  I  very  much  doubt  its  efficacy.  I 
have  more  faith  in  the  internal  use  of  iodide  of  potassium.  To  check 
secretion.  Dr.  Altstadter  extols  conium,  given  in  one  or  two-grain  doses 
four  or  five  times  a  day.  The  distinct  indication  is  to  avoid  stimulat- 
ing or  exciting  the  breasts.  If  it  be  desired  not  to  promote  the  secre- 
tion of  milk,  the  breasts  should  be  kept  in  perfect  rest.  It  is  in  carry- 
ing out  this  indication  that  the  physician  will  experience  the  greatest 
difficulty.  It  is  a  conviction  rooted  in  the  minds  of  nurses  with  all 
the  tenacity  of  prejudice,  that  friction,  and  that  not  always  gentle,  and 
"  drawing  the  breasts,"  are  necessary.  This  inflillibly  keeps  up  irrita- 
tion. Engorgement  and  inflammation  are  too  apt  to  follow.  One  con- 
dition of  rest  is  repose  in  bed,  another  is  gently  supporting  the  breasts, 
so  as  to  obviate  any  tendency  to  hanging  down ;  they  should  be  kept 
well  lifted  up  from  below  and  from  the  sides ;  the  easy  return  of  the 
blood  from  them  thus  diminishes  the  risk  of  stagnation  ;  another  way 
to  promote  rest  is  to  use  the  arms  as  little  as  possible.  If  there  be  any 
engorgement,  it  is  well  to  keep  the  arm  of  the  affected  side  in  a  sling. 
Cooling  lotions,  as  of  acetate  of  ammonia  and  alcohol,  are  useful.  It 
is  only  when  there  is  great  tension,  that  the  overflow  should  be  gently 
abstracted  by  a  breast-pump,  or,  better  still,  by  the  soda-water  bottle 
heated  by  hot  water  and  then  applied  empty,  so  as  to  draw  by  vacuum. 
This  is  far  safer  in  the  hands  of  an  ordinary  nurse  than  the  breast-pump. 
Saline  purgatives,  and  moderate  unstimulating  diet,  especially  postpon- 
ing the  conventional  stout,  are  essential  adjuncts. 

When  mammary  abscess  occurs  after  lactation  has  been  carried  on 
for  several  months,  this  is  almost  certainly  because  the  system  has  been 
so  reduced  that  it  is  no  longer  fit  to  keep  up  the  function. 

Simpson  described  (Med.  Times  and  Gaz.,  1861)  sujjerinvolution  of 
the  uterus  as  a  morbid  state  the  opposite  of  subhwolutlon.  It  is  pro- 
duced when  the  disintegrating  process  set  up  after  delivery  goes  on  to 
such  an  excessive  degree  as  to  reduce  the  uterus  to  a  size  decidedly  be- 
low its  normal  dimensions  in  the  unimpregnated  state.  He  relates  a 
case  of  a  woman  aged  20,  who  liever  menstruated  after  her  first  labor. 
Two  years  after  labor  she  was  admitted  to  the  Edinburgh  Infirmary. 
There  was  amenorrhoea,  great  constitutional  disturbance,  frequent  at- 
tacks of  diarrhoea,  which  she  believed  to  be  most  severe  at  recurring 
monthly  intervals,  the  dejections  being  sometimes  tinged  with  blood. 
The  mammse  were  shrunk  and  flat.  The  uterus  was  small ;  its  cervix 
much  atrophied,  OS  contracted.  Sound  penetrated  1.5''.  Albuminuria 
and  dropsy  preceded  death.  The  uterus  was  one-third  below  the  natu- 
ral bulk ;  the  ovaries  were  atrophied,  showing  no  Graafian  vesicles. 

27 


418  IKJUEY    TO    CERVIX     UTERI. 

Sometimes  atresia  from  cicatricial  closure  of  the  uterus  is  followed . 
by  a  true  amenorrhoea — not  simply  retention.     Dr.  Liz6  reports  such 
a  case  in  the  "Union  Medicale,"  1863.     The  uterus  seems  to  become 
atrophied  from  obstruction  to  the  performance  of  its  functions. 

In  various  parts  of  this  work,  this  process  of  hyperinvolution  is 
referred  to.  I  believe  it  is  far  from  uncommon.  Sometimes,  as  in  the 
ease  quoted  from  Mr.  Walter  Whitehead  (see  p.  402),  it  may  go  to  the 
extent  of  removing  the  uterus  altogether. 

I  have  encountered  it  sometimes  with  partial  success  by  the  use  of 
Simpson's  galvanic  pessary. 

Results  of  Injury  to  Cervix  Uteri  during  Labor. 

If  Ave  pursue  the  clinical,  and,  in  this  instance,  the  historical  order, 
in  the  study  of  the  most  common  morbid  conditions  of  the  uterus,  we 
shall  find  succeeding  the  first  stage  of  tumefaction,  ecchymosis,  and 
congestion  of  the  mucous  and  submucous  tissues  of  the  cervix,  and 
the  sliedding  of  the  bruised  epithelium,  the  following  condition :  The 
whole  cervix,  especially  the  vaginal-portion,  is  sensibly  enlarged, 
tumid,  gorged  with  blood,  oedematous ;  for  a  definite  area  around  the 
OS,  tlie  part  is  bared  of  epithelium,  giving  a  pulpy  granulating  appear- 
ance to  the  part;  this  part  is  further  divided  into  lobes  or  prominences, 
the  result  of  the  small  lacerations  which  took  place  during  the  passage 
of  the  child  ;  this  bared  part  is  red,  angry-looking  from  the  villi  being 
full  of  blood,  bathed  with  viscid  and  purulent-looking  secretion;  the 
part  of  the  vaginal-portion,  beyond  the  line  of  epithelial  denudation, 
looks  bluish-red,  owing  to  the  gorged  bloodvessels  being  seen  through 
the  epithelial  investment.  The  vaginal-portion  in  this  state  easily 
bleeds  under  examination,  under  coitus,  and  under  any  exertion  or  emo- 
tion. Leucorrhoea  is  generally  copious.  Lumbar  pain  is  constant. 
General  prostration  certainly  attends.  Some  degree  of  prolapsus  is 
rarely  absent. 

A  similar  state  exists  throughout  the  cervical  canal.  The  rugae  are 
prominent,  bared  at  least  in  part.  The  surface  is  bathed  in  viscid, 
clear,  or  turbid  mucus.  The  canal  is  more  patulous  than  usual.  In- 
tensely vascular,  and  the  vessels  badly  pi'otected  by  delicate  new  epi- 
thelium, which  is  being  shed  as  fast  as  formed,  the  intra-cervical  sur- 
face easily  bleeds,  so  that  metrorrhagia  is  common.  All  this  can  be 
easily  seen  through  the  metroscope,  or  even  in  part  through  the 
bivalved  speculum,  whose  blades,  made  to  diverge,  open  the  os  ex- 
ternum. 

Some  of  these  objective  conditions  are  fairly  illustrated  in  Fig.  94, 
drawn  from  nature  from  a  case  observed  about  a  month  after  labor. 
This  drawing  shows  also  the  enlarged  relaxed  state  of  the  fundus  of 
the  vagina  which  attends  this  stage  of  the  afPection. 

The  microscopical  condition  of  such  a  case  is  represented  in  Fig.  95, 
which  should  be  compared  with  Fig.  24,  p.  52,  which  shows  the  villi 
bared  of  epithelium  by  maceration. 

By  some  this  condition  is  called  "inflammation;"  and  the  state  of 
the  OS  uteri,  bared   of  epithelium,   is  called  "  ulceration."     In  some 


ULCERATION 


.r  " 


419 


cases,  undoubtedly,  inflammation  intervenes;  and  the  question  of  ulcer- 
ation is  one  of  doctrine.  What  is  ulceration?  If  Ave  consult  the  most 
recent  authorities  for  an  explanation,  we  find  Simon  (Holmes's  "System 
of  Surgery  ")  defining  ulceration  as  a  destructive  process  of  inflamma- 


SIiows  condition  often  observed  a  month  after  labor.    Congestion  of  vaginal-portion.    Epithelial 
denudation  around  the  os     (From  nature.  E.  B.) 


tion:  "  It  is  the  process  by  which  holes  are  made  through  the  surface- 
textures  of  the  body  (cutaneous,  mucous,  articular,  or  serous),  and 
hence  perhaps  into  deeper  parts;  a  process  which  differs  from  gangrene 
mainly  in  the  fact  that  it  proceeds  more  gradually  and  molecularly. 
At  the  place  where  an  ulcer  exists,  the  absent  texture  perished  as  truly 
as  by  gangrene ;  but  while  gangrene  would  have  occasioned  its  abrupt 
separation  in  mass,  ulceration  permitted  its  progressively  shedding  as 
detritus.  The  discharge  from  any  spreading  ulcer,  if  examined  under 
the  microscope,  invariably  exhibits  particles  of  disintegrating  tissue; 
and  the  so-called  foulness  is  but  gangrene  on  a  smaller  scale." 

Macleod  (Cooper's  "Surg,  Diet.,"  1872)  gives  a  similar  explanation. 
He  says,  "Ulceration  is  a  result  of  inflammation,  and  consists  in  the 
molecular  death  and  removal  by  minute  disintegration  and  solution  of 
the  superficial  vascular  particles  of  the  inflamed  part.  There  is  a  mi- 
nute atomic  division  of  the  particles  of  the  affected  tissue,  and  these 


420 


ULCEEATION. 


molecules  are  removed  in  the  '  ichor '  or  discharge  which  escapes  from 
the  surface  of  the  sore  or  '  ulcer '  which  forms.  The  terms  desquama- 
tion^ or  excoriation,  or  abrasion,  are  applied  to  the  removal  of  epithe- 


FiG,  95. 


(After  Hassall  and  Tyler  Smith.) 
Showing  loss  of  epithelium,  leaving  villi  of  os  uteri  bare,  and  partially  eroded. 


lium  alone,  while  ulceration  implies  a  deeper  penetration  of  the  de- 
structive action." 

If  we  next  examine  Avhat  is  meant  by  inflammation,  we  find  Simon 
givino;  the  following  account  of  what  takes  place  in  this  process : 

"  The  capillaries  allow  fluid  to  sweat  through  their  coats  from  the 
liquor  sanguinis  to  the  tissues.  In  this  way  they  minister  to  growth. 
If  the  membrane  be  ruptured  or  dissolved,  normal  transudation  is  at 
an  end,  and  capillary  hemorrhage  takes  place. 

"  The  arteries  are  more  relaxed,  carry  a  profusion  of  blood.  The 
veins  carry  more  blood  than  usual ;  but  not  all  that  the  arteries  carry 
into  the  tissues :  something  is  left  behind  in  the  tissues." 

Now,  in  the  typical  case  before  described,  is  there  not  greater  relax- 
ation of  the  arteries  ?  do  they  not  visibly  carry  more  blood  ?  do  not 
the  veins  carry  more  blood  ?  and  is  there  not  something  left  behind  in 
the  tissues  ?  It  is  impossible  not  to  answer  all  these  questions  in  the 
affirmative.  And  so  of  ulceration :  is  there  not  gradual  shedding  of 
tissue  as  detritus  ?  does  not  the  discharge  exhibit  particles  of  disinte- 
grating tissue  ?  is  there  not  a  hole  through  the  mucous  surface-texture  ? 
Or  is  this  breach  of  surface  the  result  of  gangrene?  According  to  the 
historical  and  clinical  points  of  view  from  which  I  have  regarded  the 
condition,  it  appears  to  be  a  combination  of  the  two  processes  of  gan- 
grene and  ulceration.  The  first  step  is  traumatic ;  the  mucous  mem- 
brane is  really  killed  by  the  bruising  it  underwent,  and  the  partial 
severance  from  the  deeper  textures  upon  which  it  grew.     Hence  it  is 


"ulceration."  421 

cast  oif  by  a  process  which  cannot  be  distinguished  from  gangrene. 
It  is  remarkable  that  the  area  of  epithelial  denudation  is  almost  always 
strictly  limited. 

There  is  a  more  or  less  indented  irregular  line  of  demarcation  Avhere 
the  epithelium  stops  abruptly  at  a  distance  of  about  half  an  inch  from 
the  centre  of  the  os  uteri.  This  line  represents  accurately  the  extent 
of  the  mucous  surface  which  fell  under  the  crushing  of  the  passage  of 
the  head.  The  fissures  seldom  or  never  go  beyond  this  line.  iSTor  does 
the  area  of  denudation  tend  to  spread  beyond  it.  In  this  respect  the 
case  differs  from  that  of  surface-ulceration.  If  there  be  ulceration  it 
must  be  by  destruction  of  tissue  within  this  circumscribed  area;  that  is, 
in  depth.  Of  such  action,  however,  there  is  usually  very  little.  Prob- 
ably the  eroded  appearance  of  the  bared  villi  accurately,  as  I  know  it 
is,  represented  in  Hassall's  drawing  (Fig.  95)  is  also  due,  like  the  cast- 
ing of  the  mucous  surface,  to  traumatism  and  necrosis.  I  do  not  think 
that  the  destructive  process  is  commonly  progressive  in  depth  any  more 
than  it  is  in  superficies.  The  process  is  essentially  and  truly  one  of  re- 
pair ;  often,  indeed,  arrested  by  the  excess  of  congestion  of  the  part  and 
by  the  general  blood-degradation  of  the  system.  But  still  it  is  a  rare 
event  for  this  process  of  arrested  repair  to  pass  into  the  0]>posite  condi- 
tion of  extending  destruction.  The  hypothesis  of  ulceration  has  been 
favored  by  the  aspect  of  the  denuded  part,  which  strikingly  simulates 
that  of  a  granulating  ulcer  on  the  skin.  But  the  observations  and 
figures  of  Dr.  Hassall,  in  Tyler's  Smith's  "  Memoir  on  Leucorrhoea," 
conclusively  show  that  the  apparent  granulations  are  really  the  project- 
ing villi  jutting  out  irregularly  on  the  surface,  having  lost  the  protecting 
epithelium  which  bound  down  smoothly  all  surface  inequality. 

After  all,  it  may  be  said,  this  is  a  dispute  about  words.  A  condition 
which  so  closely  corresponds  to  the  classical  definition  of  ulceration 
may  fairly  be  called  ulceration.  This  might  be  conceded,  were  it  not 
that  the  common,  vulgar  as  well  as  professional,  conception  of  ulcera- 
tion embraced  the  idea  of  a  spreading,  eroding  action ;  and  that  thus 
the  word  bears  a  more  formidable  significance  to  the  patient  than  the 
reality  justifies.  Now,  we  all  know  that  the  morbid  surface  is  not  so 
aflFected.  There  is  a  bared,  secreting,  easily  bleeding  surface  trying  to 
heal.  It  is  often  slow  to  heal.  It  may  take  weeks  and  months  to 
recover  its  normal  investment  of  epithelium  ;  but  during  all  this  time 
ulceration  cannot  be  said  to  go  on,  otherwise  than  in  the  most  languid 
imperceptible  form. 

But  another  process  is  certainly  going  on.  This  is  exudation.  The 
gorged  vessels,  through  which  their  contents  are  only  imperfectly  pro- 
pelled, leave  something  behind  in  the  tissues.  "  Exudations,"  says 
Druitt  (Article  "Inflammation,"  Cooper's  "Surgical  Dictionary,"  edi- 
tion 1872)  "cannot  remain  dormant.  They  rapidly  undergo  changes 
either  in  the  way  of  development  or  degeneration."  In  this  case  the 
tendency  is  towards  development.  This  means  hyperplasia  and  hyper- 
trophy. The  connective  tissue,  or  fibrous  tissue  of  the  cervix  especially, 
becomes  increased  in  quantity  ;  the  cervix  becomes  after  a  time  denser; 
it  elongates.     This  latter  part  of  the  process,  the  conversion  of  exuda- 


422 


ULCERATION. 


tion  into  permanent  tissue,  may  be  averted  by  subduing  the  vascular 
engorgement,  and  healing  the  denuded  surface. 

The  treatment  of  this  condition  has  been  described  in  the  preceding 
chapter.  It  consists  essentially  in  "  rest,"  tonics,  good  diet,  and  local 
astring^ents. 


Epithelial  abrasion  after  labor.    Tendency  to  hypertrophy.    (Ad.  nat.) 


If  a  cure  be  not  effected  at  this  stage,  the  case  will  often  become 
more  obstinate.  The  natural  tendency  to  heal  can  hardly  be  trusted 
to  if  the  powers  of  the  system  are  sensibly  reduced.  If  there  be  evi- 
dent anaemia  and  attendant  impairment  of  nutrition,  repair  cannot  be 
expected  to  proceed  in  a  part  exposed  to  constant  disturbances,  and  peri- 
odical fluxes  of  blood.  Generally,  the  vaginal-portion  loses  in  bulk ; 
some  degree  of  contraction  takes  place,  owing  to  the  absorption  of  the 
fluid  element  of  the  exuded  material,  and  the  condensation  of  the  plastic 
element  ensuing  upon  its  conversion  into  fibrous  tissues.  The  abraded 
area  looks  smaller,  and,  in  fact,  is  smaller,  but  this  is  often  not  so  much 
the  result  of  acutal  healing,  as  of  the  general  contraction  of  the  vaginal- 
portion.  There  is  still  a  free  secretion  of  mucus,  viscid,  coming  from 
the  cervical  cavity.  There  is  still  more  or  less  vascular  engorgement, 
and  some  infiltration  of  tissue,  with  recent  exudation.  The  denuded 
area  looks  red,  granular,  like  a  strawberry  or  raspberry.  The  vagina 
is  still  relaxed,  and  some  degree  of  epithelial  shedding  goes  on  from  its 
mucous  membrane.  The  lumbar  and  dorsal  pains  persist.  There  is 
often  pain  in  the  seat  of  one  or  other  ovary,  generally  as  Bennet  says, 
in  the  left. 

The  treatment  is  still  the  same  as  for  the  earlier  stage.  The  denuded 
surface  should  be  lightly  touched  every  five  or  six  days  with  nitrate 
of  silver,  and  the  like  application  should  be  made  to  the  interior  of 
the  cervical  canal.  If  this  cause  much  pain  or  bleeding,  the  solid 
sulphate  of  zinc  should  be  substituted.  Vaginal  lotions  of  zinc,  alum, 
bark,  or  tannin  should  be  used  daily.  If  there  be  any  prolapsus,  a 
Hodge  pessary  will  be  of  essential  service  in  maintaining  ''  rest,"  and 
diminishing  the  local  engorgement. 

Under  this  treatment,  the  denuded  surface  will  often  get  covered  in 
in  a  few  weeks,  and  the  excessive  vascularity  will  be  reduced.  But 
exudation  has  taken  place;  and  exudation  has  been  followed  by  new 


FLUXION.  423 

growth.  This  hypertrophy,  even  altliough  not  attended  by  much  in- 
crease of  bulk,  so  as  to  induce  prohipsus,  or  dragging,  or  pressure 
upon  surrounding  organs,  is  ahnost  always  attended  by  irritation, 
which  keeps  up  increased  attraction  of  blood,  hypertrophy  of  the 
elands,   and  free  leucorrhoea.     Pain   continues  to   wear  the  nervous 

... 

centres.     Healthy  nutrition  is  prevented. 

At  this  stage,  the  application  of  potassa  cum  calce  or  the  actual 
cautery  to  one  or  the  other  lip  of  the  os  uteri  will  often  exert  the  most 
beneficial  influence.  The  mode  of  applying  these  agents  will  be  de- 
scribed under  the  treatment  of  chronic  metritis. 

The  further  history  of  hypertrophy,  or  fibroid  degeneration  of  the 
cervix  uteri,  will  be  traced  in  connection  with  that  of  prolapsus. 


CHAPTER  XXXIX. 

CONDITIONS  MAKKED  BY  ALTERED  VASCULAKITY  OR  BLOOD- 
SUPPLY:   FLUXION;  HYPEREMIA;  CONGESTION; 
INFLAMMATION. 

The  vascular  system  of  the  genital  organs  and  the  proportion  of 
blood  supplied  may  be  in  excess  or  deficiency. 

The  conditions  characterized  by  excess  may  be  distinguished  as — 
1.  Fluxion  or  simple  determination  of  blood.  2.  Hyperoemia.  3.  Con- 
gestion or  Engorgement.  4.  Inflammation.  The  conditions  character- 
ized by  deficiency  are  summed  up  in  Anaemia. 

Whilst  fluxion,  hypersemia,  or  congestion  may  each  stop  short,  in- 
flammation implies  the  previous  existence  of  fluxion  and  congestion. 
It  may  be  regarded  as  the  climax  of  the  first  three  conditions. 

1.  Fluxion  in  its  simplest  form  may  be  defined  as  a  transitory  flow 
of  blood  to  the  parts.  One  example  of  it  may  be  compared  to  the 
rush  observed  in  the  cheeks  under  the  emotions  of  shame  or  anger. 
The  uterus  and  ovaries  are  certainly  subject  to  similar  determinations 
of  blood  under  the  influence  of  various  emotions,  as  the  sexual  passion, 
and  of  reflex  irritation,  as  that  produced  by  the  child  sucking  at  the 
breast.  This  fluxion  is  of  course  perfectly  physiological ;  and,  if  oc- 
curring in  healthy  organs,  entails  no  ill  eifects,  unless  it  be  artificially 
and  inordinately  stimulated. 

An  example  of  simple  fluxion  is  the  physiological  determination  of 
blood  excited  by  ovulation  at  the  menstrual  periods. 


424  FLUXION. 

The  vascular  fulness  determined  by  the  developmental  attraction  of 
pregnancy  may  be  regarded  as  an  example  of  fluxion.  Analogous  to 
this  is  the  fulness  dependent  upon  the  abnormal  developmental  attrac- 
tion produced  by  the  growth  in  the  uterus  of  fibroid  tumors.  One 
diiference  which  exists  in  the  two  cases,  is  that  in  the  first,  the  fluxion 
is  more  uniformly  persistent,  less  disturbed  by  the  periodical  molimen 
of  ovulation ;  it  is  a  steadily  maintained  active  hypersemia.  In  the 
second,  the  persistent  hypersemia  induced  by  the  developmental  stimu- 
lus is  further  liable  to  the  periodical  molimen  of  ovulation.  Hence 
the  tendency,  where  fibroid  tumors,  polypi,  or  cancer  exist,  to  metror- 
rhagia. 

Fluxion  has  its  pathological  as  well  as  its  physiological  significance. 
Using  the  term  in  this  relation,  it  takes  the  place  of  those  states  com- 
monly described  as  "  active  hypersemia,"  and  "  active  congestion."  As 
Billroth  observes,^  the  vessels  dilate  or  suffer  themselves  to  be  dis- 
tended, under  the  influence  of  some  irritation,  and  then  quickly  dis- 
gorge themselves  when  the  irritation  has  ceased.  It  may  be  difficult  to 
discover  the  true  cause,  but  it  is  generally  easy  to  observe  the  phe- 
nomenon. The  exafffferated  afflux  of  blood  is  the  reaction  or  the 
response  of  a  vascularized  jaart  excited  to  irritation :  "  ubi  stimuhis 
ibi  Jluxus." 

If  the  ovaries  and  uterus  be  in  an  abnormal  condition,  whether  from 
congestion,  inflammation,  displacement,  from  being  the  seat  of  new 
formations,  their  liability  to  fluxes  is  increased.  The  diseased  organs 
will  commonly  be  even  more  susceptible  than  the  healthy  to  irritations 
which  provoke  the  afflux  of  blood. 

If  the  uterus  be  imperfectly  involved  after  pregnancy,  or  engorged, 
or  its  tissues  relaxed  from  other  causes,  this  fluxion,  otherwise  harm- 
less, may  give  rise  to  hemorrhages.  And  it  is  probable  that  the  hem- 
orrhages so  arising  act  in  some  cases  as  an  evacuant,  saving  the  uterus 
from  passing  into  congestion  or  inflammation. 

Fluxion,  then,  may  occur  in  healthy  organs,  and  in  diseased  organs. 
Therefore,  when  studying  the  pathology  of  the  ovaries  and  uterus,  we 
must  bear  in  mind  not  only  their  actual  or  essential  morbid  conditions, 
but  also  the  influence,  beneficial  or  injurious,  of  accesses  of  fluxion  to 
which  they  are  liable.  These  fluxions,  in  fact,  form  a  most  important 
element  in  the  history  of  uterine  and  ovarian  diseases.  They  are  the 
immediate  occasion  of  some  of  the  most  distressing  and  dangerous  phe- 
nomena. By  being  prepared  for  them,  by  moderating  their  intensity, 
or  by  preventing  their  recurrence,  we  shall  often  accomplish  the  most 
useful  therapeutical  results. 

It  may  be  doubted  whether  simple  physiological  fluxion,  howsoever 
frequently  repeated,  will  often  produce  inflammation  of  the  uterus, 
ovaries,  or  their  investing  peritoneum.  It  is  true  that  peritonitis  and 
oophoritis  are  common  in  prostitutes,  and  that  these  events  are  attribut- 
able to  sexual  excesses.  But  it  is  certain  that  in  many  of  these  cases 
the  determining  cause  has  been  the  propagation  of  gonorrhoeal  inflam- 
mation, or  exposure  to  cold  or  other  form  of  violence. 


1  "  Elements  dc  Pathologie  Chirurgioale  Generale,"  1868. 


FLUXION.  425 

The  chief  symptoms  of  simple  fluxion  are  subjective.  The  patient 
feels  a  sensation  of  local  heat  and  fulness,  depending  upon  the  turgidity 
of  the  organs  affected,  and  the  tension  of  the  j^lexuses  and  erectile  por- 
tions of  the  vascular  system. 

The  fluxion  may  subside  as  quickly  as  it  arose;  and  it  mostly  leaves 
the  organs  exactly  in  their  previous  condition,  unless  they  were  dis- 
eased ;  in  which  case  the  fluxion,  especially  if  often  repeated,  may  pro- 
dace  injurious  consequences.  Should  varicose  veins  exist  in  the  legs, 
thighs,  or  groins,  the  effect  of  fluxion  is  seen  in  a  marked  manner  at 
the  menstrual  periods.  The  veins  visibly  swell,  become  tumid,  deeper 
colored  ;  and  the  patient  is  conscious  of  the  increased  turgidity. 

When  fluxion  occurs  in  morbid  structures,  the  symptoms  are  com- 
monly more  severe.  Pain  is  more  marked ;  the  sense  of  fulness,  of 
weight,  is  more  oppressive ;  dragging  pain  is  felt  in  the  loins  and 
groins ;  and  often,  sharp  colic  spasms  in  the  stomach  in  the  region  of 
the  umbilicus.  In  the  more  severe  cases,  and  depending  somewhat 
upon  the  kind  and  degree  of  the  local  morbid  condition,  the  fluxion 
develops  all  the  symptoms  of  congestion.  The  vascular  fulness  seeks 
relief  in  discharges ;  these  present  themselves  as  hemorrhage,  leucor- 
rhoeal  or  mucous  discharges,  and  escape  from  the  mucous  membrane  of 
the  uterus,  vagina,  bladder,  or  rectum.  These  are  sometimes  accom- 
panied by  dysenteric  and  dysuric  pains. 

Certain  general  symptoms  precede  and  attend  the  local  phenomena. 
The  premonitory  signs  may  be  defined  as  an  exaggeration  of  those 
which  mark  the  approach  of  the  ordinary  menstrual  molimen.  There 
is  a  state  of  tension  marked  by  a  chill  or  even  by  a  rigor,  by  spasm, 
vague  nervous  phenomena,  irritability  or  depression  of  temper,  rest- 
lessness, perhaps  hysteria. 

The  attendant  signs  are  the  reactionary  phenomena  which  reveal  the 
participation  of  the  organism  in  the  distress  of  the  uterus.  There  is 
an  exasperation  of  the  nervous  erethism,  circumscribed  pains  in  certain 
parts,  neuralgia,  gastric  disturbance,  headaches  ;  and,  lastly,  when  the 
fluxion  is  often  repeated,  or  has  continued  an  unusual  time,  there  occur 
what  seem  to  be  blood-determinations  to  the  heart  and  lungs. 

The  objective  dgns  are :  distension  of  the  hypogastrium,  increase  of 
heat,  and  slight  development  of  pain  on  pressure.  The  vagina  is  re- 
laxed, perhaps  secreting  mucus ;  the  uterus  is  increased  in  bulk,  lower 
in  the  pelvis,  and  is  tender  to  the  touch.  The  variation  of  volume  ob- 
served in  the  uterus  is  at  times  very  great.  For  example,  in  a  case  of 
anteversion  I  have  felt  the  uterus,  at  the  time  of  the  menstrual  fluxion, 
assume  twice  its  usual  size,  and  return  to  its  ordinary  bulk  as  the 
fluxion  subsided.  The  neck  of  the  uterus  feels  softer,  swollen.  For 
the  time  the  mucous  membrane  of  the  uterus  and  vagina  is  of  a  deep- 
red  color. 

Courty  describes  a  chronic  fluxion.  But  it  appears  to  me  that  the 
essence  of  the  idea  of  fluxion  is  an  active  transitory  flow.  When  the 
vascular  tension  of  a  part  becomes  permanent,  there  is  either  hyper- 
semia  or  congestion. 

The  treatment  of  fluxion  will,  of  course,  be  determined  by  the  degree 
of  the  affection,  and  by  the  condition  of  the  organs  to  which  the  flux- 


426  FLUXION. 

ion  is  determined.  Even  the  ordinary  physiological  fluxion  of  the 
menstrual  period  requires  some  management,  for  influences,  otherwise 
harmless  or  even  beneficial,  may,  as  is  well  known,  act  at  this  time 
injuriously.  The  treatment  consists  in  the  observance  of  hygienic 
precautions,  and  these  may  be  also  summed  up  in  the  one  word,  "  Rest." 

The  treatment  of  fluxion  in  diseased  organs  resolves  itself  in  part 
in  the  special  treatment  adapted  to  relieve  the  disease.  But  the  fluxion 
itself  demands  special  management.  The  periodical  fluxions  of  men- 
struation we  ought  to  be  prepared  for.  "  Kest "  here  is  even  more 
important  than  in  the  simple  fluxion.  But  the  irregular  fluxions,  pro- 
voked by  accidental  emotional  and  local  irritations,  cannot  always  be 
foreseen  or  guarded  against.  Familiarity  with  the  idiosyncrasy  and 
surroundings  of  the  patient,  however,  will  often  enable  us  to  avert 
some  of  these  irritations. 

We  have  the  indication  of  one  natural  mode  of  relief  of  fluxion  in 
the  hemorrhage  of  menstruation ;  and  of  another  in  the  quiet  subsi- 
dence of  the  local  vascular  excitement.  If  the  fluxion  occur  at  a 
menstrual  epoch  it  will  be  pretty  sure  to  seek  relief  in  hemorrhage  by 
an  exaggeration  of  the  normal  menstrual  flow.  It  will  rarely  be  neces- 
sary to  take  measures  to  excite  or  to  increase  the  flow.  It  will  more 
often  be  necessary  to  moderate  it ;  for  it  is  one  of  the  remarkable  phe- 
nomena of  hemorrhage  that  when  once  begun,  fluxion  is  determined 
with  increased  force  towards  the  organ  whence  blood  finds  a  ready 
escape.  The  bleeding  organ  seems  to  acquire  the  faculty  of  attracting 
more  blood  from  the  aorta,  only  to  pour  it  out  of  the  system.  The 
heart  becomes  excited,  and  acts  with  greater  force  and  frequency.  The 
chain  of  the  circulation  is  broken.  The  blood  escapes  at  the  capillaries 
instead  of  being  carried  on  to  the  veins ;  and  in  some  cases,  perhaps 
many,  there  is  reason  to  believe  that  the  raptus  towards  the  accidental 
outlet  is  so  active  that  blood  is  even  drawn  towards  it  in  a  retrograde 
course  from  the  veins.  These  phenomena  are  nowhere  so  well  marked 
or  so  easily  observed  as  in  the  hemorrhage  of  the  gravid,  puerperal 
and  diseased  uterus.  The  treatment  of  hemorrhage  is  considered  else- 
where. Our  only  point  here  is  how  to  manage  the  fluxion.  There  is 
one  very  effective  agent  in  turning  away  the  fluxion  from  the  organ 
predestined  to  be  its  seat,  which  it  is  almost  hopeless  to  recommend  at 
the  present  time.  The  doctrine  of  revulsion  teaches  that  we  may  divert 
the  torrent  of  the  circulation  from  an  organ  towards  which  irritation 
conducts  it,  by  setting  up  an  artificial  fluxion  to  another  part.  This 
is  most  certainly  effected  by  venesection.  This  principle  of  controlling 
the  circulation  was,  perhaps  is,  in  great  repute  on  the  Continent.  I 
have  frequently  seen  it  most  beneficially  acted  upon  by  Lisfranc.  A 
small  bleeding  from  the  arm,  timely  practiced,  may  not  only  save  a 
greater  effusion,  by  turning  aside  the  current  from  the  morbid  surface, 
but  by  lessening  the  vascular  activity  in  the  diseased  organ,  may  check 
the  progress  of  the  disease. 

The  condition  of  usefulness  from  bleeding  depends  upon  the  observ- 
ance of  the  principle  of  revulsion.  The  bleeding  must  be  practiced 
at  a  distance  from  the  organ  we  want  to  relieve.  It  need  not  be  large 
in  amount.     A  few  ounces  drawn  from  the  arm  by  venesection  or  from 


HYPEREMIA.  427 

the  temples  or  nuclia  by  leeches,  will  commonly  suffice.  It  should, 
however,  be  remembered  that  all  fluxions  are  not  alike  benefited  by 
this  treatment.  It  is  especially  useful  in  young  plethoric  persons  ;  and 
when  the  fluxion  is  recent  or  only  im2)ending.  It  is  also  useful  in 
some  cases  of  more  languid  fluxion  in  women  laboring  under  hepatic 
difficulty,  or  heart  disease  disposing  to  retrograde  portal  obstruction. 

Another  form  of  revulsive  treatment,  less  powerful,  and  more  likely 
to  commend  itself  to  current  ideas,  consists  in  causing  derivation  to 
the  skin  or  intestinal  canal.  By  epispastics,  by  blisters,  or  fomenta- 
tions, we  can  excite  some  degree  of  local  afflux  to  a  distant  j)art  of  the 
body.  By  purgatives  we  can  cause  a  derivation  to  the  intestines,  and 
take  off  some  degree  of  vascular  tension,  by  exciting  the  flow  of  the 
watery  ingredients  of  the  blood. 

A  revulsive  recommended  by  Hippocrates,  is  the  application  of  dry- 
cupping  to  the  breasts.  The  illustrious  father  of  medicine  well  knew 
the  sympathy  which  existed  between  the  breasts  and  the  ovaries  and 
uterus.  This  idea  has  in  recent  times  been  applied  by  the  Germans, 
and  the  late  Dr.  Rigby,  to  excite  the  uterus  to  contract  after  labor,  and 
by  Scanzoni,  who  sought  to  provoke  labor  by  thus  stimulating  the 
breasts.  Courty  speaks  highly  of  the  efficacy  of  dry-cupping  the 
breasts  to  obtain  the  revulsive  effect  we  are  discussing.  I  am  able  to 
give  a  qualified  approval  to  the  practice  of  Rigby.  That  of  Scanzoni 
has  been  condemned  by  the  results  of  observation.  The  irritation  of 
the  breasts,  whilst  not  always  fulfilling  the  purposes  in  view,  not  sel- 
dom caused  inflammation  and  abscess.  I  should  fear  similar  accidents 
from  Courty's  practice,  especially  as  he  insists  that  the  method,  to  be 
useful,  must  be  kept  up  for  several  hours,  even  days.  It  is  further 
open  to  the  objection  that  irritation  of  the  breasts  is  likely  to  excite 
fluxion  to  the  uterus,  and  thus  to  cause  the  very  accident  it  is  sought 
to  avert.  Again,  it  is  not  desirable,  for  obvious  reasons,  to  irritate  the 
breasts  in  young  women. 

Certain  medicines  possess  the  valuable  property  of  allaying  and  reg- 
ulating vascular  excitation.  Of  these  the  most  useful  are  tlie  acetate 
of  ammonia,  nitrate  of  potash,  tartarated  antimony,  aconite,  digitalis. 

A  very  useful  formula  is — I^.  Liquoris  ammonise  acetatis,  5iij ;  ni- 
tratis  potassffi,  gr.  xv ;  vini  antimonialis,  5j  ;  infusi  digitalis,  5ij  ; 
aquae,  .5j-  M.  This  dose  may  be  taken  every  three  or  four  hours.  It 
determines  to  the  skin  and  intestinal  canal ;  it  may  possibly  provoke 
nausea  or  vomiting,  but  this  has  a  powerful  influence  in  checking  hemor- 
rhage. 

2.  Hypercemia  must,  I  think,  be  distinguished  from  fluxion  on  the 
one  hand,  and  from  congestion  on  the  other.  It  is  a  continuous  or 
chronic  fulness  of  the  vessels  of  a  ])art  which  does  not  necessarily  imply 
morbid  action  in  that  part,  but  which  at  most  leads  to  languid,  passive, 
changes. 

Hypersemia  occurs  especially  in  connection  with  excessive  menstrual 
congestion ;  the  uterus  is  full  of  blood,  dark-red,  swollen,  softened ;  the 
mucous  membrane  is  injected,  red,  swollen,  with  a  spongy  flocculent 
aspect  from  the  development  of  its  uterine-tubular  glands,  softened  and 
bleeding. 


428  CONGESTION    OF    UTEEUS. 

The  development  of  the  uterine  glands  is  at  times  quite  extraordi- 
nary. Rokitansky  saw  in  the  body  of  a  girl,  who  died  in  course  of 
typhus  whilst  menstruating,  the  raucous  membrane,  especially  on  the 
posterior  uterine  wall,  dark-red,  and  converted  into  a  thick  stratum  of 
villous-looking  folds  packed  together,  in  which  the  uterine  glands  were 
elongated  to  Q"  or  more.  I  have  specimens  of  dysmenorrhoeal  decidua 
showing  the  same  thing. 

In  the  course  of  typhus,  cholera-typhoid,  the  exanthemata,  scurvy, 
ypersemia  of  the  uterine  mucous  membrane  occurs. 

The  uterus  becomes  hypersemic  and  swollen  when  the  pelvic  system 
of  veins  is  overloaded,  and  especially  when  flexions  or  displacements 
of  the  organ  exist.  In  the  latter  cases,  the  hypersemia  is  most  marked 
in  the  anterior  or  posterior  wall. 

New  formations  cause  and  keep  up  hypersemia,  sometimes  more 
marked  in  the  uterine  substance,  sometimes  in  the  mucous  membrane. 
It  also  occurs  in  heart  disease,  in  obstructions  to  the  return  of  blood 
through  the  vena  cava.  Often,  it  principally  aifects  the  lower  segment 
of  the  cervix  and  the  vaginal-portion. 

Persisting  hypersemia  leads  to  persistent  secretion  of  mucus,  and  to 
hypertrophy  of  the  uterus,  commonly  of  the  eccentric  form ;  to  hyper- 
trophy of  the  vaginal-portion,  Avith  predominance  of  the  connective 
tissue ;  and  thence  to  induration,  the  so-called  infarctus.  Hyperasmia 
disposes  to  oedema  of  the  tissues  and  to  hemorrhage.  The  hemorrhage 
takes  place  from  the  mucous  membrane  into  the  uterine  cavity  as  the 
expression  of  the  hyperemia.  The  outpoured  blood  flows  away,  or 
sometimes,  even  without  marked  obstruction  of  the  canal,  forms  clots, 
or  one,  which  compressed  takes  the  form  of  the  uterine  cavity. 

There  is  often  a  chronic  pelvic  hypersemia  in  aged  women,  leading 
to  hemorrhage.  The  hypersemia  is  mostly  due  to  portal  obstruction 
and  to  the  general  vascular  want  of  tone  arising  from  obesity  and  want 
of  exercise.  This  state  may  induce  softening,  fragility  of  the  uterine 
substance,  and  fragility  of  its  vessels. 

Its  seat  is  the  fundus,  and  especially,  almost  exclusively,  says  Roki- 
tansky, the  posterior  wall.  The  soft  uterine  substance  looks  black- 
red,  infiltrated  with  blood  so  as  not  to  be  recognizable,  and  blood  is 
seen  in  variable  quantity  in  the  tissues  when  section  or  rent  is  made. 
The  mucous  membrane  is  commonly  in  the  same  condition  ;  and  often 
blood  is  found  in  the  uterine  cavity  (the  apoplexia  uteri  of  Cruveil- 
hier). 

If  the  vaginal-portion  be  examined  by  the  speculum  it  is  seen  to  be 
swollen,  dark-red,  and  the  whole  vagina  commonly  exhibits  the  same 
appearance.  There  is  a  sense  of  weight  and  heat ;  often  some  degree 
of  prolapsus ;  and  also  a  troublesome  form  of  pruritus. 

Considerable  improvement  sometimes  follows  a  spontaneous  hemor- 
rhage ;  and  hyperemia  being  essentially  a  passive  condition  due  to  su- 
perior obstruction,  a  few  leeches  applied  to  the  os  uteri  will  occasionally 
be  serviceable.  But  our  chief  effort  should  be  directed  to  correcting 
the  condition  of  the  central  organs  of  circulation  and  digestion,  to  re- 
storing the  general  health,  and  to  removing  any  uterine  complication. 

3.  Congestion  or  engorgement  of  the  uterus  and  ovaries.     This  con- 


CONGESTION     OF    UTERUS.  429 

dition  implies  a  moi'e  prolonged  fulness  of  the  vessels  than  mere  fluxion ; 
it  rarely  exists  without  some  amount  of  retardation  of  the  blood  in  the 
vessels,  that  is,  hypereemia ;  and  this  retardation  almost  certainly  en- 
tails more  or  less  effusion  of  the  serous  or  aqueous  elements  of  the  blood 
into  the  tissues  of  the  organs  affected.  This  implies  swelling  or  tume- 
faction. Once  set  up,  this  condition  is  extremely  liable  to  persist. 
The  frequently  dependent  position  of  the  organs  favors  the  accumula- 
tion of  blood  in  them,  whilst  their  liability  to  fluxes,  under  the  influ- 
ences already  mentioned,  is  a  constant  source  of  aggravation  and  imped- 
iment to  cure. 

Congestion  may  arise  from  many  causes.  If  the  organs  are  caught 
whilst  under  the  influence  of  physiological  fluxion  by  constitutional 
shock,  by  exposure  to  cold,  or  protracted  fatigue,  fluxion  may  pass  into 
congestion. 

Congestion  of  the  uterus  very  frequently  takes  its  rise  in  the  state 
of  imperfect  contraction  and  involution  following  pregnancy  and  labor. 
The  relaxed  tissues  -and  dilated  vessels  form  a  ready  receptacle  for  the 
blood,  and  the  want  of  tone  and  contractility  obviously  favors  its  reten- 
tion. 

Whatever  the  cause  of  congestion,  it  is  soon  aggravated  by  displace- 
ment of  the  womb.  Implying,  as  congestion  does,  increased  bulk  and 
weight,  and  attended,  as  it  almost  necessarily  is,  by  relaxation  of  the 
structures  which  ought  to  support  the  womb,  this  organ  almost  invari- 
ably sinks  lower  in  the  pelvis,  or  its  body  falls  backwards  or  forwards. 

On  the  other  hand,  an  abnormal  position  of  the  womb  may  predis- 
pose to  congestion.  Retroflexion  or  anteflexion  may  be  primary. 
Under  the  repeated  rushes  of  ovulation,  of  sexual  relations  and  other 
causes,  congestion  is  brought  about  by  the  obstruction  which  the  dis- 
placement interposes  to  the  return  of  blood. 

The  effect  of  displacement  is  almost  surely  to  add  to  the  congestion. 
Take,  for  example,  the  case  of  ante  version  or  retroversion.  The  body 
of  the  uterus  rolled  over  on  its  transverse  axis  in  the  broad  ligaments, 
twists,  distorts,  and  compresses  the  vessels  at  the  point  of  entry  and  exit. 
Blood  still  enters  the  uterus  by  virtue  of  the  propelling  vis  a  terc/o 
through  the  arteries ;  but  the  veins,  thin-walled,  flaccid  and  valveless, 
rendered  tortuous  and  compressed,  afford  but  a  difficult  return.  This 
state  gives  rise  to  what  French  authors  distinguish  as  engorgement,  but 
which  it  seems  more  convenient  to  describe  as  a  phase  or  consequence 
of  congestion.  It  is  difficult  to  imagine  that  pure  congestion  can  long 
exist  without  giving  rise  to  the  infiltration  of  tissue  which  constitutes 
engorgement. 

Uterine  congestion  complicates,  or  plays  an  important  part  in,  a  large 
proportion  of  cases  of  uterine  disease.  It  constitutes  one  of  the  most 
serious  obstacles  to  their  cure.  It  tends,  by  its  very  conditions,  to  per- 
petuate itself.  It  exhibits  little  or  no  tendency  towards  spontaneous 
recovery.  The  organ  in  which  it  occurs  is  rendered  permanently 
larger,  its  tissues  are  infiltrated  with  serum  or  semi-plastic  extravasa- 
tions, its  contractile  force,  the  tonicity  of  its  vessels  are  impaired ;  the 
blood  brought  to  the  uterus,  either  by  the  ordinary  distribution  or  by 
intermittent  fluxions,  is  delayed ;  a  kind  of  hsemostasis  is  induced ; 


430  CONGESTION    OF    UTERUS. 

and  these  conditions  are  aggravated  by  time,  by  the  increasing  mechani- 
cal impediment  to  the  course  of  the  pelvic  circulation,  which  displace- 
ment of  the  uterus  in  relation  to  the  broad  ligaments  induces. 

Uterine  congestion  may  be  primary,  and  for  an  indefinite  time  con- 
stitute the  chief  morbid  condition.  As,  however,  we  have  had  fre- 
quent occasions  to  observe,  it  rarely  exists  long  without  inducing  dis- 
placement, as  prolapsus  of  the  uterus;  and  sooner  or  later,  it  is  likely 
to  lead  to  other  evils,  as  hypertrophy  and  inflammation. 

It  may  be  secondary  upon  other  conditions.  There  is  one  which  in 
my  experience  almost  infallibly  induces  congestion.  That  is  the  fixing 
of  the  womb ;  whether  this  be  from  perimetric  adhesions,  from  com- 
pression of  tumors,  from  pressure  against  the  symphysis  pubis  by  retro- 
uterine hffimatocele,  or  other  cause. 

The  symptoms  of  congestion  are  essentially  the  same  as  those  which 
mark  the  combination  of  fluxion  and  hyperBemia;  the  diagnostic  test 
being  the  persistence  of  the  symptoms,  and  the  accidental  intermittent 
character  of  the  fluxions  which  may  or  may  not  complicate  this  con- 
gestion. There  is  also  more  pain  than  in  bypersemia.  The  enlarged 
uterus,  by  its  proximity  to  the  bladder  and  rectum,  irritates  these 
organs,  keeps  up  hypersemia  or  congestion  in  the  surrounding  pelvic 
tissues.  The  reflex  excitation,  or  the  proximate  irritation,  causes  fre- 
quent desire  to  void  urine,  and  dysuria ;  the  same  causes  induce  dys- 
chezia,  tenesmus,  straining,  at  times  diarrhoea.  Expulsive  efforts  are 
caused,  at  first  involuntary,  afterwards  perhaps  intensified  by  the  semi- 
involuntary  bearing-down  excited  by  the  sensation  that  there  is  some- 
thing to  be  expelled.  The  contraction  of  the  abdominal  walls,  as  in 
the  act  of  defecation,  of  sneezing,  of  coughing,  is  attended  by  indirect 
pelvic  pain,  more  or  less  acute. 

A  frequent  consequence  of  congestion  is  dysmenorrhoea.  This  symp- 
tom, when  not  accounted  for  by  obstruction  from  stenosis  or  angu- 
lation of  the  uterine  canal,  is,  I  believe,  most  commonly  due  to  the 
accumulation  of  blood  in  the  uterine  cavity,  its  coagulation  there, 
and  retention,  which  is  favored  by  the  quantity  poured  out.  It  has 
time  to  clot,  partly  because  its  quantity  is  in  excess  of  the  mucus  which 
helps  to  keep  it  fluid,  and  partly  because  it  is  allowed  to  rest  by  the 
uterus,  whose  power  of  contraction  is  enfeebled  by  the  congestion. 
Retention  means  irritation,  and  irritation  means  uterine  colic,  that  is, 
dysmenorrhoea.  This  symptom  is  the  more  certain  to  follow  in  pro- 
portion to  the  degree  of  displacement  of  the  uterus. 

The  difficulty  which  congestion  occasions  to  the  uterus  in  the  per- 
formance of  its  functions  becomes  a  source  of  aggravation  of  the  con- 
gestion. It  not  uncommonly  happens  that  the  menstrual  function  is 
disordered  in  its  periodicity,  as  well  as  in  its  other  characters.  The 
patient  often  becomes  irregular,  sometimes  she  even  loses  the  reckoning 
so  as  no  longer  to  know  when  her  periods  are  due.  The  menstrual  flow 
is  merged  in  hemorrhage.  It  may  last  for  a  week  or  a  fortnight, 
leaving  a  fortnight  or  three  weeks  interval  only ;  or  a  flow  of  blood, 
which  it  becomes  difficult  to  distinguish  as  menstrual,  appears  at 
irregular  intervals.     Not  seldom,   however,   the  menstrual   discharge 


CONGESTION    OF    UTERUS.  431 

becomes  scanty,  or  ceases  to  be  noted  otherwise  than  doubtfully  in  the 
shape  of  irregular  discharges  of  blood. 

Leucorrhoea  is  an  almost  constant  effect  of  congestion ;  the  gorged 
vessels  of  the  uterus  seek  relief  by  secretion  of  mucus  ;  and  Rokitan- 
sky  has  shown  that  the  glands,  under  hypersemia  and  congestion, 
undergo  enormous  development. 

The  local  signs  are  the  increased  bulk  and  weight  of  the  organ,  in- 
volving diminished  mobility,  and  more  or  less  displacement  expressed 
by  prolapsus,  anteversion,  or  retroversion,  and  sometimes  flexion.  By 
the  speculum  the  vaginal-portion  is  seen  swollen,  deep  red.  The  vagi- 
nal-portion and  cervical  cavity  easily  bleed  on  examination  by  touch, 
speculum,  or  sound. 

Congestion  is  often  more  or  less  limited  to  the  vaginal-portion  when 
there  is  stenosis  of  the  os  uteri  externum.  This  condition  is  discussed 
under  the  head  of  "  Dysmenorrhoea."  Congestion  of  the  vaginal- 
portion  also  occurs  in  prolapse  with  hypertrophy  of  the  vaginal-portion. 
In  this  condition  the  vaginal-portion  is  liable  to  get  constricted  by  the 
circular  compression  of  the  vagina,  and  between  the  bowel  and  bladder. 
This  constriction  retards  the  circulation  in  the  lowest  part  of  the  vagi- 
nal-portion, makes  it  tumid,  and  increases  the  disposition  to  liyper- 
trophy.  This  is  exemplified  in  a  figure  from  a  preparation  in  King's 
College  Museum.     (See  Prolapsus  :  hypertrophy.) 

Congestion  may  affect  the  whole  uterus ;  or  it  may  affect  the  body 
or  the  cervix  only.  In  all  cases  the  congestion  bears  most  obviously 
on  the  mucous  membrane. 

The  treatment  of  congestion  and  engorgement  must  be  determined 
greatly,  in  most  instances  primarily,  by  the  indications  for  the  removal 
of  the  complicating  conditions.  Thus,  attending  prolapsus,  version, 
or  flexion,  demands  special  care.  The  displacement  corrected,  the  as- 
sociated congestion  will  almost  certainly  be  relieved,  if  not  removed. 
The  management  of  the  complications  is  described  where  they  are 
treated  of  as  primary  or  essential  disorders. 

It  is  necessary  to  remember  that  congestion  or  engorgement  of  the 
uterus  is  curable,  whilst  old-standing  hypertrophy  is  not. 

Again,  many  women  who  have  passed  the  climacteric,  scarcely  need 
to  be  treated  for  .congestion.  This  condition,  when  existing,  is  no 
longer  so  liable  to  exacerbation  by  fluxions;  it  becomes  more  passive; 
the  pain  subsides ;  and  tolerance  is  acquired.  But,  on  the  other  hand, 
youth  is  favorable  to  cure ;  the  activity  of  the  circulation  and  of  all 
the  functions  facilitates  the  absorption  of  effused  matters;  and  the  very 
functions  of  the  uterus,  as  menstruation  and  pregnancy,  by  virtue  of 
the  retrograde  involution  which  seizes  upon  the  uterus  when  these 
functions  are  completed,  may  involve  the  morbid  hyperplastic  struc- 
tures, and  thus  dissolve  them.  A  remarkable  example  of  this  process 
is  seen  in  the  occasional  diminution  or  even  disappearance  of  fibroid 
tumors  after  labor. 

The  question  of  local  depletion  when  there  is  congestion  is  important. 
Its  action  is  powerful,  and  resort  to  it  requires  discretion  both  as  to  the 
selection  of  the  cases  and  the  method  to  be  employed.  If  the  con- 
gestion is  liable  to  periodical  aggravation,  especially  if  attended  by 


432  LEECHING. 

hemorrhages,  from  menstrual  fluxion,  the  principle  of  derivation  and 
revulsion  already  discussed,  should  be  invoked.  Where  the  congestion 
is  accompanied  by  intense  pain  and  sense  of  weight,  the  bulk  of  the 
uterus  being  sensibly  increased,  benefit  will  sometimes  be  derived  from 
local  depletion.  This  may  be  practiced  either  by  leeching  or  scarifi- 
cation. Leeching  has  been  extensively  employed  in  the  treatment  of 
uterine  disease ;  and  if  one  may  be  permitted  to  judge  from  the  obser- 
vation of  cases  where  it  has  failed  to  do  good,  or  has  done  harm,  under 
the  advice  of  other  practitioners,  I  should  say  that  it  is  employed 
much  too  often.  The  effect  of  the  suction  of  leeches  on  the  lower  seg- 
ment of  the  uterus  is  often  to  attract  blood  to  the  pelvic  organs.  The 
free  anastomoses  of  the  branches  of  the  internal  iliac,  the  numerous 
plexiform  structures,  the  numerous  valveless  veins  constitute  a  peculiar 
formation  unfavorable  to  local  bleeding  by  exhaustion.  The  vascular 
system  of  the  pelvis  has  been  likened,  not  inaptly,  to  a  sponge.  Draw 
blood  from  any  one  part,  and  it  is  immediately  replaced  by  a  new  sup- 
ply ;  the  vessels  can  hardly  be  emptied ;  you  may  attract  any  quantity 
of  blood  through  this  channel,  producing  marked  systemic  effect, 
but  the  local  engorgement  may  be  little  diminished.  That  this  is  often 
the  effect  of  leeching  the  os  uteri  and  upper  part  of  the  vagina  I  am 
very  confident ;  and,  therefore,  I  now  resort  to  this  practice  with  very 
great  circumspection. 

The  method  of  scarification  is  not  open  to  the  same  objection,  at 
-least  not  to  nearly  the  same  extent.  Superficial  scratches  or  incisions 
made  on  the  vaginal-portion  will  give  vent  to  the  blood  gorging  the 
part  operated  upon,  without  entailing  a  fresh  fluxion  to  the  organ. 
The  most  marked  benefit  from  incisions  in  the  vaginal-portion,  is  often 
seen  when  the  os  externum  is  divided  on  account  of  stenosis  and  dys- 
menorrhoea.  In  this  condition  the  mucous  membrane  is  often  intensely 
gorged ;  and  when  cut,  it  is  left  pale  and  less  swollen  by  the  very 
moderate  loss  of  blood  which  attends  the  operation. 

The  mode  of  applying  leeches  to  the  cervix  uteri  is  to  introduce  a 
Fergusson's  or  other  tubular  speculum,  bringing  the  cervix  well  into 
the  field ;  wipe  off  any  secretion  with  a  bit  of  cotton-wool  or  sponge ; 
then  put  the  leeches,  three  or  four  in  number,  into  the  speculum,  and 
push  them  down  upon  the  cervix  by  a  pledget  of  cotton-M^ool.  The 
operation  is  often  troublesome,  and  this  is  another  objection  to  it.  The 
leeches  at  times  refuse  to  bite,  and  worm  their  way  out  most  insidi- 
ously between  the  wool  plug  and  the  speculum,  and  easily  escape  alto- 
gether unless  carefully  watched.  One  leech  at  a  time  may  be  more 
conveniently  applied  by  means  of  a  long  glass  tube  open  at  the  uterine 
end,  and  provided  with  a  piston  to  push  the  leech  onwards.  In  London 
there  are  several  nurses  who  take  charge  of  this  little  operation  for  a 
moderate  fee. 

Scarification  is  to  be  preferred  to  leeching  for  the  reason  assigned, 
and  also  because  it  is  more  convenient  to  carry  out.  The  operation  is 
performed  through  a  speculum.  The  most  suitable  specula  are  Sims's, 
Neugebauer's,  or  Cusco's.  These  have  the  advantage  of  bringing  the 
OS  uteri  nearer  to  the  outlet,  of  exposing  it  more  freely  and  under 
greater  tension,  than  the  tubular  speculum.    Almost  any  bistoury  long 


METRITIS.  433 

enough,  may  be  used,  but  it  is  most  convenient  to  employ  such  a  scari- 
ficator as  that  designed  by  Dr.  Routh.  It  is  a  small  lancet  carried  by 
a  forceps  and  kept  fast  by  two  pins  which  go  through  the  forceps.  It 
gives  stabs  into  the  vaginal-portion  rather  less  than  half  an  inch  deep. 
The  number  and  depth  of  the  stabs  will  be  determined  by  the  nature 
of  the  case,  and  the  flow  which  follows  the  first  one  or  two  punctures. 


CHAPTER  XL. 

METRITIS  :  ENDOMETRITIS  ;  FOLLICULAR  EXCORIATIONS  ; 
/  APHTHOUS  ERUPTIONS;  VARICOSE  ULCER. 

In  practice  what  is  called  endometritis  or  uterine  catarrh,  meaning, 
more  or  less  precisely,  inflammation  of  the  mucous  membrane  of  the 
uterus,  is  the  form  of  metritis  the  most  frequently  met  with,  and  that 
presumedly  as  a  distinct  disease.  It  might  on  this  ground  be  con- 
sidered desirable  to  describe  it  separately.  But  regarding  the  fre- 
quency of  its  com^^lication  with  inflammation  of  the  parenchyma,  either 
in  its  origin  or  in  its  course,  it  appears  to  me  on  the  whole  more  useful 
to  study  metritis  and  endometritis  together.  In  discussing  the  treat- 
ment, it  will  not  be  difficult  to  point  out  the  modifications  which  the 
predominance  of  one  or  the  other  form  may  especially  indicate. 

Metritis  may  be  analyzed  as  follows :  1.  There  is  the  puerperal 
metritis  springing  from  convection  of  foul  matter  in  the  venous  and 
lymphatic  channels,  from  the  cavity  of  the  uterus.  This  usually  runs 
a  rapid  course,  and  when  fatal,  it  is  rather  by  general  infection  of  the 
circulation  and  peritonitis,  than  from  the  simple  metritis. 

This  puerperal  metritis  may  be:  a,  general,  or  b,  limited  more  or 
less  to  that  portion  of  the  uterine  wall  which  corresponds  with  the 
attachment  of  the  placenta. 

Both  forms  are  likely  to  be  attended  by  peritonitis.  Both  may  be- 
come chronic.  In  either  case,  the  normal  involution  will  be  retarded, 
and  the  uterus  will  remain  larger  than  normal. 

2.  Very  similar  conditions  may  follow  in  the  non-pregnant  state, 
from  the  slow  necrotic  inflammation  to  which  polypi  and  fibrous  tumors 
are  prone;  from  necrotic  or  inflammatory  changes  in  cancerous  growths; 
from  peculiar  fungoid  or  other  morbid  conditions  of  the  uterine  mucous 
membrane. 

3.  We  are,  perhaps,  most  familiar  with  acute  metritis,  apart  from 

28 


434  METRITIS. 

the  puerperal  state,  as  the  result  of  injury  or  irritation  produced  by 
surgical  treatment.  Thus,  operations  upon  the  uterus,  as  incision  of 
the  cervix :  scraping,  or  cutting,  or  tearing  away  of  iibroid  tumors ; 
the  application  of  caustics  to  the  interior  of  the  uterus,  especially  in 
the  form  of  injections ;  the  use  of  tents,  laminaria  or  sponge ;  and 
above  all  the  wearing  intra-uterine  pessaries,  may  induce  metritis.  In 
all  these  cases  there  may  be  absorption  of  foul  matter  by  the  vessels 
which  permeate  the  walls  of  the  uterus. 

In  all  these  cases,  the  inflammation  mostly  invades  all  the  tissues  of 
the  uterus,  mucous,  muscular,  vascular,  and  peritoneal,  and  almost 
invariably  spreads  to  the  cellular  tissue  on  either  side  of  the  neck, 
involving  the  broad  ligaments.  Generally,  the  extra-uterine  inflam- 
mation predominates  over  the  metritis  proper. 

Metritis  may  he  simple  or  complicated.  The  inflammatory  complica- 
tions are :  inflammation  of  the  ovary,  of  the  tubes,  of  the  perimetric 
cellular  tissue,  of  the  pelvic  peritoneum,  perimetric  phlegmons  or 
abscesses,  lymphangitis,  phlebitis,  phlegmasia  dolens.  All  these  com- 
plications, or  some  of  them,  may  arise  not  only  as  consequences  of  labor, 
but  also  from  suppressed  menstruation,  cold,  local  injury,  conditions 
arising  out  of  uterine  tumors,  or  of  tubercular  or  cancerous  disease. 

Dr.  West  has  described  as  ''metritis  hsemorrhagica "  the  intense 
acute  inflammation  which  occurs  when  a  piece  of  nitrate  of  silver  falls 
into  the  cavity  of  the  uterus.  In  such  a  case,  free  hemorrhage  is  very 
apt  to  arise. 

The  diflFerence  of  structure  and  of  function  of  the  cervical  portion  of 
the  uterus  confers  upon  it  pathological  liabilities  distinct  from  those  of 
the  body  of  the  organ.  It  may  be  true  that  by  continuity  of  tissue, 
and  by  receiving  its  blood  supply  in  great  part  from  the  same  vascular 
system,  inflammation  of  the  cervix  is  apt  to  spread  to  the  body,  and 
vice  versd ;  but  practically,  we  often  have  to  deal  with  cases  in  which 
one  or  the  other  part  is  so  much  more  profoundly  affected  than  the  other, 
that  it  demands  special  attention. 

This  consideration,  and  the  advantage  of  avoiding  much  repetition, 
have  led  me  to  curtail  in  this  place  the  description  of  inflammation  of 
the  cervical  portion.  The  complement  of  this  subject  will  be  found  in 
the  section  devoted  to  the  changes  consequent  on  labor,  and  in  that  on 
prolapsus  and  hypertrophy. 

Inflammation  of  the  Substance  of  the  Uterus.     Metritis. 

The  inflammation  of  the  submucous  stratum  which  occurs  in  acute 
endometritis  spreads  sometimes  to  the  whole  uterine  substance,  and 
rises  to  such  a  height  that  the  uterus  swells  to  the  size  of  a  goose's  egg, 
becomes  softened,  reddened,  unusually  succulent  and  infiltrated  with 
small  extravasations.  This  acute  metritis  next  invades  the  peritoneal 
covering  of  the  uterus  and  of  the  neighboring  organs.  In  some  rare 
cases  the  issue  has  been  in  suppuration,  and  the  formation  of  abscesses 
in  the  walls  of  the  uterus,  AS'hich,  like  the  puerperal  abscesses,  lead  to 
various  secondary  destructive  actions. 

Chronic  metritis  proceeds  from  the  acute  form,  or  is  developed  out  of 


METRITIS.  435 

persistent  hyperseraia.  It  not  uncommonly  arises  slowly,  even  insid- 
iously, out  of  irritation  produced  by  other  morbid  conditions,  as  tumors 
or  cancer ;  and  that  without  being  preceded  by  any  condition  that  can 
rightly  be  called  acute  inflammation.  It  leads  to  hypertrophy  of  the 
uterus,  with  preponderance  of  the  connective  tissue,  which  affects  the 
whole  organ  or  prevails  in  the  body,  cervix,  or  vaginal-portion.  Its 
most  frequent  foundation  is  undoubtedly  laid  in  retarded  involution 
after  labor.  Much,  therefore,  of  what  might,  in  strict  order,  be  dis- 
cussed in  this  place,  has  been  anticipated  in  the  chapter  on  the  conse- 
quences of  labor ;  and  which  should,  therefore,  be  read  in  connection 
with  the  description  of  metritis. 

Chronic  metritis  thus  takes  its  rise  in  hypersemia.  Whatever  pro- 
duces retardation  and  accumulation  in  the  uterus  or  in  the  utero-ovarian 
system  of  vessels,  leads  to  chronic  metritis.  Scanzoni^  says  the  influ- 
ence of  heart  disease  in  producing  chronic  metritis  is  underestimated. 
Stenosis  and  insufficiency  of  the  mitral  valves,  by  inducing  retrograde 
venous  stagnation,  causes  hypersemia  of  the  uterus.  He  also  insists 
that  chlorosis  and  other  forms  of  anaemia,  by  favoring  pelvic  hyper- 
semia,  frequently  lead  to  chronic  metritis. 

Scanzoni  has  distinguished  two  stages  of  metritis ;  namely,  1,  a  stage 
of  infiltration  or  softening,  in  which  is  observed  more  or  less  extensive 
hypersemia,  a  sero-sanguinolent  infiltration  of  the  uterine  tissue,  which 
in  consequence  becomes  soft,  relaxed,  thickened ;  and  2,  a  stage  of 
thickening  or  induration,  in  which  general  or  partial  anaemia  of  the 
organ,  dryness,  firmness,  and  hardness  of  tissue  are  the  principal  lesions. 

In  the  first  stage,  that  of  softening  and  hypereemia,  there  may  be 
excess  or  alteration  in  the  secretions  of  the  mucous  follicles  ;  especially, 
new  formations  may  arise,  or  there  may  be  general  hypertrophy  of  the 
organ.  In  this  stage  the  softened  uterus  is  flaccid,  so  that  it  can  be 
bent  backwards  or  forwards,  and  pressure  of  the  finger  leaves  a  depres- 
sion. The  surface  of  the  organ  often  exhibits  stringy  peritoneal  adhe- 
sions to  the  neighboring  structures.  When  a  section  is  made  with  a 
scalpel,  there  is  absence  of  that  crying  sound  which  is  heard  when  the 
healthy  dense  tissue  is  cut  through.  It  is  like  cutting  through  an 
ordinary  muscle.  Fluid  blood  flows  from  the  cut  vessels,  and  serum 
from  the  tissue.  The  cut  vessels  are  seen  of  larger  calibre,  gaping  in 
places,  but  not  universally.  In  intervening  spaces  the  vessels  may,  to 
the  naked  eye,  show  no  alteration.  The  parenchyma  itself  has  lost 
something  of  its  resistance,  it  is  more  succulent  and  friable.  The  in- 
crease in  thickness  of  the  wall  at  this  stage,  Scanzoni  says,  is  not  demon- 
strably due  to  increase  of  muscular  fibre,  but  mainly  to  the  serous  infil- 
tration. It  is  more  swelling  than  new  growth.  He  has  also  observed 
advanced  fatty  metamorphosis  of  the  muscular  bundles,  and  in  the 
interposed  connective  tissue  a  great  number  of  free  fat-globules.  This 
more  especially  applies  to  the  upper  part  of  the  organ.  The  mucous 
membrane  is  almost  invariably  the  seat  of  chronic  catarrh. 

In  the  second  stage,  that  of  thickening  or  induration,  there  is  a  gen- 
eral or  partial  anaemia  of  the  organ.     The  tissue  is  dry,  tough,  and 

1  Die  Chronische  Metritis,  1863. 


436  METRITIS. 

hard.  This  hardness  strikes  the  observer  as  the  next  feature  after  the 
increase  of  volume.  The  hardness  resembles  that  of  dense  fibroid 
tumors.  These  characters  are  very  clearly  seen  when  the  hypertrophied 
vaginal-portion  is  amputated.  This  tissue-change,  Scanzoni  says,  is 
more  evident  in  the  posterior  than  in  the  anterior  wall,  and  he  attrib- 
utes this  to  the  fact  that  the  hinder  wall  is  the  more  frequent  seat  of 
the  placenta.  The  indurated  places  look  pale,  yellow,  or  yellowish- 
red,  and  this  appearance  is  made  more  striking  in  those  cases  where 
these  places  are  surrounded  by  others  still  in  the  stage  of  infiltration, 
and  which  will  be  soft  and  red.  But  cases  are  frequently  observed  in 
which  the  whole  organ  is  thickened  and  indurated.  In  the  hardened 
parts  the  vessels  are  contracted.  The  chief  contribution  to  the  increase 
of  volume  of  the  tissue  is  made  by  excessive  growth  of  the  connective 
tissue,  although  the  muscular  element  may  to  some  extent  contribute. 
As  far  as  I  can  trust  my  own  observations  made  upon  the  hypertrophied 
vaginal-portion  after  amputation,  I  must  concur  in  this  statement. 
The  same  operation  also  gives  evidence  of  the  contraction  of  the  ves- 
sels. Incision  made  with  the  knife  divides  no  large  vessels ;  there  is 
at  most  an  oozing  from  the  "surface.  The  greatest  part  of  the  blood 
comes  from  the  divided  mucous  membrane. 

Chronic  metritis,  although  it  may  predominate  in  the  body  or  cervix, 
almost  invariably  affects  the  entire  uterus,  more  or  less.  Scanzoni  has 
taken  great  pains  to  verify  the  statements  of  those  pathologists  who 
contend  that  the  anterior  or  posterior  wall  or  the  fundus  may  be  the 
especial  seat  of  hypertrophy  from  chronic  inflammation.  He  has  occa- 
sionally found  a  part  more  thickened  than  the  rest ;  but  invariably  the 
entire  body  of  the  organ  is  enlarged.  The  growth  is  outwards;  it 
leaves  the  cavity  expanded,  impairing  more  or  less  its  triangular  shape, 
so  that  it  becomes  more  ovoid. 

The  mucous  membrane  is  swollen,  softened ;  the  glandular  orifices 
are  prominent,  open,  visible  under  water.  The  gland-tubes  themselves 
are  much  elongated.  Mucus,  stained  with  pus,  is  generally  found  in 
the  cavity. 

The  origin  of  the  increase  of  bulk,  undoubtedly,  in  many  cases,  lies 
in  acute  metritis.  The  effused  fluids  not  being  entirely  absorbed,  that 
which  remains  becomes  organized.  But  there  are  many  cases  in  which 
it  is  difficult  to  prove  the  existence  of  inflammation.  Under  simple 
hypersemia  fluids  are  efFused  into  the  tissue,  and  the  non-absorbed  ex- 
cess may  undergo  the  same  change  into  dense  tissues.  It  is  thus  that, 
during  long-persistent  hypersemia,  there  may  be  intercurrent  attacks 
of  metritis.  But  this  is  not  shown  to  be  necessary — the  process  is  one 
of  disordered  nutrition. 

The  changes  produced  in  the  cervix  uteri  by  chronic  inflammation 
involving  the  whole  uterus  have  been  partly  described  in  a  preceding 
chapter.  Those  which  are  necessarily  dependent  upon  antecedent  preg- 
nancy are  the  following : 

The  foUiGular  excoriations  of  the  cervical  canal  arise,  according  to  C. 
Mayer,  in  the  following  manner :  There  is  an  inflammatory  process  in 
the  mucous  membrane,  so  that  the  follicles  being  involved,  their  excre- 
tory orifices  are  closed.     Then  three  several  pathological  changes  pro- 


METRITIS.  437 

ceed  :  1.  The  follicles  swell  gradually  to  the  size  of  a  millet-seed,  and 
form  round,  smooth,  elastic  cysts,  containing  a  delicate,  viscid,  stringy 
matter,  known  as  ovula  Nabothi.  Often  the  contents  assume  a  pur- 
ulent condition ;  and  at  length  the  follicles  burst,  and  leave  round  fol- 
licular ulcerations.  2.  The  follicles  do  not  reach  the  above-described 
development,  but  stop  as  it  were  on  the  way,  as  small,  roundish  bodies 
with  thickened  investments,  and  scanty  contents,  like  hard  knots  on 
the  surface,  and  so  persist.  3.  Or  the  follicles  project  more  and  more 
out  of  the  mucous  membrane,  like  ovula  Nabothi,  become  bigger,  and 
hang  down,  stalked,  like  scarlet-red  pearls,  out  of  the  os  uteri.  These 
are  called  mucous  polypi. 

These  three  forms  give  rise  to  three  distinct  forms  of  follicular 
erosions  and  ulcerations,  different  in  their  symptoms  and  in  their  ap- 
pearance. 

In  the  first  form  the  os  uteri  is  nearly  always  large,  gaping,  its 
scarred  borders  everted  ;  its  whole  surface  feels  rough,  uneven.  The 
profuse  secretion  is  often  yellowish,  puriform,  not  seldom  mixed  with 
blood,  and  offensive.  The  lips  are  dark-red,  even  purple,  hypei-semic. 
The  prominent  smooth  follicles  are  easily  recognized  ;  they  have  a  tur- 
gescent,  often  finely  granular  surface.  A  thick  stream  of  opaque,  yel- 
lowish-white secretion  flows  from  the  cervix.  Where  the  follicles 
have  burst,  roundish  ulcers  remain.  The  condition  is  not  limited  to 
the  OS  uteri,  it  extends  to  the  interior  of  the  cervix. 

These  follicular  affections,  C.  Mayer  says,  are  almost  always  asso- 
ciated with  chronic  metritis.  Scanzoni  associates  them  with  retarded 
involution  of  the  uterus.  The  mucous  membrane,  with  its  glandular 
apparatus,  hypertrophied  during  pregnancy,  remain  stationary,  and 
give  rise  to  the  affections  described.  That  this  is  in  many  cases  true, 
1  do  not  doubt.  But  the  explanation  I  have  given  in  the  chapter  on 
the  changes  the  cervix  undergoes  after  labor  is,  I  am  equally  sure, 
more  generally  true.  The  mucous  membrane,  at  least  its  epithelial  ele- 
ment, falls  by  a  necrotic  process ;  and  one  does  not  usually  see  in  the 
post-puerperal  cases  distinct  rounded  follicular  ulcers,  but  a  large  sur- 
face bared  of  epithelium ;  the  granular  aspect  being  due,  not  so  much 
to  the  enlarged  follicles,  as  to  the  swollen  villi,  no  longer  bound  down 
by  their  epithelial  investment.  The  roundish  erosions,  resulting  from 
burst  follicles  described  by  Maver,  are  often  seen  independently  of 
pregnancy,  that  is,  years  after  the  last  pregnancy,  and  even  in  women 
who  have  never  had  children. 

There  is  another  form  of  erosions  described  by  Scanzoni  and  others, 
which  ought  not  to  be  confounded  with  the  foregoing.  These  result  from 
aphthous  eruptions.  Partly  in  the  immediate  proximity  of  the  os  uteri, 
partly  scattered  at  some  distance,  are  small  vesicular  points  as  big  as  a 
pin's  head.  The  epithelium  is  easily  rubbed  off  by  a  brush,  leaving  a 
small  vivid  red  spot.  Sometimes  several  of  these  vesicles  run  together, 
and  give  rise  to  a  large  erosion.  This  kind  of  erosion  is  distinguished 
from  the  preceding  one,  in  the  absence  of  follicular  swelling  of  the 
cervical  mucous  membrane,  by  the  thinness  of  the  superficial  wall  of 
the  vesicle,  by  the  ease  with  which  the  vesicles  burst,  and  in  their 
leaving,  not  a  sharp  deep  ulcer,  but  ^  superficial,  perhaps  irregular. 


438  METRITIS. 

erosion.  This  appears  to  be  the  herpetic,  dartrous  or  eczematous 
ulceration  of  Huguier  and  Courty,  terms,  which  I  think  Aran  rightly 
finds  fault  with,  since  they  imply  a  connection  with  herpetic  disorders 
of  the  skin,  of  which  there  is  no  proof.  On  the  other  hand,  Scanzoni 
relates  a  case  of  an  otherwise  healthy  woman  who  suffered  from  aphthae 
of  the  mouth,  who,  whenever  she  had  a  fresh  eruption  here,  always  had 
attacks  of  pruritus  vulvae  and  slight  leucorrhcea,  attended  by  vesicular 
eruption  on  the  mucous  membrane  of  the  vaginal-portion.  These  were 
speedily  cured  by  light  touches  with  nitrate  of  silver ;  but  a  relapse 
always  followed  the  formation  of  aphthae  in  the  mouth. 

The  'papillary  erosions  I  have  described  under  the  changes  follow- 
ing labor  under  the  name  of  "  villous."  I  believe  they  are  more  fre- 
quently the  cause  than  the  consequence  of  chronic  metritis.  Dating 
from  the  act  of  labor,  arising  in  traumatism,  they  precede  metritis. 
Although  the  metritis  may,  and  often  does,  arise  out  of  the  hyperaemia 
attending  retarded  involution,  yet  even  in  cases  where  involution  has 
proceeded  fairly  well,  the  raw  surface  left  by  the  fall  of  the  epithelium 
keeps  up  irritation  and  attracts  an  undue  flow  of  blood  to  the  part ; 
maintaining  a  condition  constantly  liable  to  merge  into  subacute  in- 
flammation. 

In  connection  with  chronic  metritis,  it  is  not  rare  to  find  a  form  of 
erosions  to  which  the  name  of  "cock's-comb  ulceration"  has  been 
given.  It  appears  to  be  a  transition-form  from  the  papillary  or  villous 
erosion  to  the  cauliflower-excrescence.  When  this  occurs,  the  tume- 
faction and  enlargement  of  the  whole  cervix  as  well  as  of  the  vaginal- 
portion  are  considerable.  There  is  intense  hyperaemia,  and  often  some 
degree  of  loss  of  mobility  of  the  lower  segment  of  the  uterus.  This 
appears  to  be  due,  at  least  in  those  cases  where  evidence  of  malignant 
disease  is  not  pronounced,  to  infiltration  of  serum,  with  some  inflam- 
matory process  in  the  cellular  tissue  immediately  outside  the  cervix. 
These  cases  are  difficult  to  deal  with.  Absolute  rest  is  essential.  Local 
applications  of  chromic  or  nitric  acid  answer  the  most  effectually. 

Scanzoni,  in  1856,  described  the  "varicose  ulcer"  as  a  form  of  dis- 
ease of  the  cervix  uteri -arising  in  this  way:  Some  time  after  the  exist- 
ence of  a  marked  increase  of  volume  of  the  uterus,  and  of  a  profuse 
secretion  from  its  cavity,  a  bluish-red  coloration  is  developed  on  the 
vaginal-portion  and  the  adjoining  part  of  the  vagina ;  some  dark  blue 
spots  gradually  appear,  upon  which,  after  a  time,  numerous  varicose 
venous  branches  become  manifest.  Upon  these  spots  the  mucous  mem- 
brane softens,  and  forms  elevations  recognizable  by  sight  and  touch. 
The  epithelium  is  thrown  off",  and  an  erosion  is  the  result.  At  a  fur- 
ther stage  the  loss  of  substance  extends  deeper,  usually  giving  rise  to 
free  hemorrhage.  The  surface  of  the  sore  looks  remarkably  pulpy,  so 
that  the  sound  easily  penetrates  it.  Scanzoni  has  only  seen  these  vari- 
cose ulcers  in  women  who  had  borne  children,  and  in  whom  there  had 
long  existed  obstruction  to  the  portal  circulation,  or  in  the  subjects  of 
heart  disease.  I  have,  however,  notes  of  a  case  taken  at  the  London 
Hospital,  in  which  there  was  a  vascular  naevus-like  growth  on  the 
OS  uteri  of  a  woman  who  had  never  had  children.  She  was  said  to 
have  had  three  abortions ;  but  tlie  cervix  and  os  uteri  had  the  features 


METRITIS.  439 

which  I  have  almost  invariably  found  significant  of  sterility.  This 
woman  had  frequent  metrorrhagia.  Under  applications  of  nitrate  of 
silver  the  varicose  mass  disappeared,  and  the  hemorrhage  ceased. 

Chronic  metritis  sometimes  brings  about  a  papillary  swelling  of  the  ' 
mucous  membrane  of  the  vagina.  This  was  at  one  time  called  "fol- 
licular." But  since  Hassall,  Henle,  Mandl,  Kolliker,  and  others,  have 
shown  that  the  mucous  membrane  of  the  vagina  is  nearly  destitute  of 
glands,  the  papillary  nature  of  the  affection  has  been  recognized.  It 
is  generally  attended  by  a  profuse  milky  or  creamy  leucorrhoea.  This 
papillary  hypertrophy  is  often  observed  in  the  course  of  pregnancy, 
which  condition  must  be  regarded  as  its  chief  cause.  After  labor  it  is 
sometimes  so  marked  as  to  resemble  a  papilloma. 

The  Course  of  Metritis. — Inflammation,  if  it  does  not  terminate  in 
resolution,  may  become  chronic,  and  lead  to  hypertrophy,  or  it  nlay 
tend  to  softening  and  liquefaction.  This  termination  is,  I  believe,  not 
very  uncommon  in  women  past  the  climacteric.  In  such  cases  the 
whole  organ  is  enlarged.  It  feels  flaccid,  swollen,  pulpy,  between  the 
internal  and  external  examining  fingers.  The  body  falls  either  for- 
wards or  backwards,  or  may  seem  to  squat  down  on  the  vagina.  The 
sound  passes  the  os  internum  easily,  provided  there  is  no  flexion,  or 
when  the  downbent  body  is  tilted  up.  It  penetrates  usually  rather 
more  than  two  and  a  half  inches  before  resistance  is  encountered ;  and 
the  wall  of  the  uterus  is  so  pulpy,  that  the  point  might  easily  penetrate 
into  or  through  its  substance.  More  or  less  oozing  of  blood  commonly 
follows  the  examination.  By  the  speculum  the  os  externum  and  vagi- 
nal-portion are  seen  deep  purple  or  dark  red;  the  mucous  membrane 
is  villous-looking ;  it  easily  bleeds. 

If  there  be  a  tubercular  element  complicating  this  metritis,  recovery 
is  hardly  to  be  expected.  It  may  be  doubted  whether,  even  apart 
from  such  complication,  recovery  takes  place,  if  the  softening  be  gen- 
eral or  far  advanced. 

Abscess  in  the  uterine  wall  is,  I  believe,  rarely  seen  unless  in  the 
puerperal  state ;  and  in  this  case  it  does  not,  unless  exceptionally, 
arise  in  the  parenchyma,  but  may  be  traced  from  the  foci  formed  in 
the  venous  tissues  or  lymphatics,  whose  walls  are  first  inflamed  by  the 
reception  of  septic  matter  from  the  cavity  of  the  uterus.  Abscess  does 
not  occur  readily  in  purely  muscular  tissue. 

Metritis  proper  may,  however,  run  on  rapidly  to  the  formation  of 
abscess,  as  in  the  following  case  told  by  Scanzoni.  A  young  woman 
had  violent  metritis  after  suppression  of  menstruation.  The  pains 
were  very  acute,  resisting  all  treatment  for  eight  days.  The  sensibility 
increased,  rigors  were  repeated  several  times,  and  suddenly  there  was 
developed,  above  the  horizontal  portion  of  the  pubes,  a  tumor  the  size 
of  a  hen's  egg,  somewhat  resisting,  and  accurately  defined.  On  the 
twenty-second  day  of  the  illness,  symptoms  of  violent  and  extensive 
peritonitis  set  in,  and  the  patient  died  on  the  thirty-first  day.  Dissec- 
tion proved  that  the  cause  of  death  was  the  rupture  of  an  abscess,  situ- 
ated in  the  right  and  upper  part  of  the  uterus,  the  pus  from  which  had 
worked  through  the  outer  strata  of  the  uterus  and  its  peritoneal  in- 
vestment. 


440  METRITIS. 

It  can  hardly  be  doubted  that  this  case  was  one  of  metritis  proper 
passing  into  abscess.  But  a  case  related  by  Hervez  de  Ch^goin  (Soc. 
de  Chirurgie,  1868),  in  M'hich  an  abscess  was  found  at  the  fundus  of 
'  the  uterus  quite  closed,  the  size  of  a  uterus  at  the  fifth  month  of  preg- 
nancy, with  enormous  development  of  the  fleshy  fibre,  was  probably 
the  result  of  suppuration  in  a  fibro-cystic  tumor. 

Amongst  the  consequences  of  chronic  metritis,  Scanzoni  lays  stress 
upon  the  frequent  implication  of  the  ovaries.  Supplied  by  the  same 
system  of  vessels,  these  readily  partake  in  the  like  hypersemia,  and  in 
the  increased  action  attending  the  uterine  condition.  He  says  ovarian 
cysts  are  a  frequent  complication.  They  arise  out  of  chronic  oophor- 
itis ;  probably  in  this  way  an  ovum  may  ripen,  but  owing  to  the  thick- 
ened condition  of  the  surrounding  stroma  the  follicle  cannot  burst,  and 
the  fluid  cannot  escape.  Succeeding  menstrual  periods  with  attendant 
hypersemia  cause  fresh  exudation  into  the  follicular  cavity,  and  so  this 
grows  to  a  cyst.  The  other  forms  of  cystoid  of  the  ovary  are  also  often 
found  as  complications  of  chronic  metritis. 

Chronic  catarrh  of  the  Fallopian  tubes  often  comes  as  an  extension 
of  the  affection  of  the  uterus ;  and  one  of  its  consequences  is  adhesion 
to  the  ov^ary.  And,  either  by  adhesion  or  by  simple  closure  of  the 
tube  at  its  abdominal  end,  the  tube  may  become  distended  by  accumu- 
lation, producing  dropsy. 

The  vagina,  in  the  higher  grades  of  the  disease,  is  almost  constantly 
in  the  state  of  chronic  catarrh,  with  more  or  less  swelling  and  relaxa- 
tion of  its  tissues.  This  is  especially  true  of  the  upper  part  or  fundus 
of  the  vagina. 

The  bladder  participates  in  the  disordered  circulation  of  the  pelvis, 
being  involved  in  chronic  catarrh,  and  perhaps  thickening  of  its  coats. 

The  rectum  is  also,  in  like  manner,  liable  to  chronic  catarrh,  at- 
tended with  various  dilatations  of  the  hsemorrhoidal  veins,  especially 
when  there  is  retroversion  or  retroflection  of  the  uterus  with  enlarge- 
ment. 

In  various  ways  the  skin  shows  evidence  of  disordered  nutrition. 
Hebra  says  the  influence  w^hich  uterine  disorder  exerts  over  the  origin 
of  skin  diseases,  especially  of  the  eczemata,  is  manifested  in  the  fact 
that  all  the  chronic  skin  affections  in  women  undergo  a  marked  deteri- 
oration, a  fresh  irritation,  during  menstruation.  Many  women,  he 
says,  feel  a  day  or  two  before  this  process — commonly  in  the  course  of 
the  vessels  of  the  extremities — smarting,  burning,  and  twitching,  so 
that  by  these  symptoms  they  can  foretell  with  certainty  the  speedy 
appearance  of  menstruation. 

Hebra  also  calls  attention  to  the  frequency  with  which  women  suf- 
fering from  uterine  disorder  lose  their  hair.  Every  one  who  sees  much 
of  these  disorders  is  familiar  with  this  complaint.  In  not  a  few  cases 
it  is  associated  with  syphilitic  complication.  But  I  am  satisfied  that 
in  a  great  number  of  cases  there  is  no  reason  to  invoke  this  explana- 
tion. It  appears  to  be  induced  by  the  deteriorated  nutrition  which 
follows  upon  chronic  uterine  disease.  It  is  often  cured,  the  hair- 
growth  being  quite  restored  when  the  uterine  disease  is  removed. 

The  influence  on  pigmentation  is   often  very  striking.     Independ- 


METRITIS.  441 

ently  of  the  pale,  sallow,  or  dull  earthen  hue,  the  result  of  the  circula- 
tion of  impoverished  blood,  more  or  less  tainted  with  unhealthy  ele- 
ments, there  are  frequently  seen  on  the  face,  namely,  on  the  forehead, 
cheeks,  or  skin,  brownish  spots  or  patches  of  lentigo  or  chloasma  uteri- 
num. This  chloasma  is  a  form  of  pityriasis  versicolor.  I  have  seen 
marked  examples  on  the  chest,  which  underwent  striking  increase  in 
depth  of  color  during  menstruation.  Although  in  all  likelihood  due 
to  disordered  nutrition  of  the  skin,  it  is  not  determined  whether  the 
yellowish-brown  color  of  the  epidermic  scales  depends  upon  the  pecu- 
liar fungus  developed  in  this  disease,  as  G.  Simon  believes,  or  upon 
the  marked  accumulation  of  fat — smegma — as  AYedl  suggests. 

Acne  is  not  at  all  uncommon.  I  have  known  this  disfiguring  erup- 
tion disappear  soon  after  cure  of  uterine  disorder,  aided  by  iodide  of 
potassium,  arsenic,  and  other  appropriate  remedies. 

Fugitive  attacks  of  erythema,  erysipelas,  or  furuncle,  are  more  fre- 
quently observed  during  the  ansemia  of  amenorrhoea,  but  are  not  un- 
common at  the  climacteric  period. 

Nervous  symptoms  or  complications. — The  seat  and  intensity  of  the 
pain  are  very  variable.  There  is  most  commonly  a  painful  sense  of 
weight,  pressure,  at  times  of  forcing,  in  the  hypogastrium  and  pelvis. 
This  is  more  or  less  constant,  but  is  aggravated  by  standing,  walking, 
or  other  exertion.  There  is  often,  a  sensation  as  of  a  large  body  tend- 
ing to  force  its  way  out  of  the  vulva.  On  coughing,  sneezing,  or  other 
forcible  expiratory  acts,  the  pain  is  increased,  and  these  bring  out  new 
pains  in  the  loins,  sacrum,  and  groins.  There  is  often  distress  at  the 
anus,  and  down  the  thighs.  At  the  menstrual  epochs,  the  hyper- 
sesthesia  is  more  generally  diffused.  The  frequency  with  which  pain 
is  felt  in  those  regions  which  are  supplied  by  the  lumbar  plexus,  is 
remarkable.  It  is  deserving  of  attention  in  a  diagnostic  point  of  view, 
that  the  intense  pain  often  complained  of  in  chronic  metritis  in  the 
inguinal  regions  is  so  explained,  and  is  therefore  not  indicative  of 
oophoritis.  In  two  cases,  says  Scanzoni,  in  which  an  autopsy  was 
made  of  women  who  had  suffered  intensely  from  pain  in  the  ovarian 
region,  so  that  he  was  all  but  convinced  that  they  had  organic  disease 
of  the  ovaries,  these  organs  were  found  perfectly  sound.  Bennet,  as 
we  have  seen,  has  long  insisted  that  this  pain  is  pathognomonic  of 
chronic  inflammation  of  the  cervix.  I  have  on  several  occasions  known 
intense  ovarian  pain  produced  at  the  moment  of  touching  an  abraded 
surface  of  the  os  uteri  with  caustic. 

The  nerve  most  frequently  affected  appears  to  be  the  ilio-hypogastric. 
The  pain  often  runs  along  the  course  of  this  nerve  from  the  anterior 
border  of  the  crest  of  the  sacrum,  downwards  to  the  inguinal  ring. 
When  the  pain  extends  to  the  labia  pudendi,  we  have  to  conclude  that 
the  external  pudic  nerve  has  been  seized.  I  have  known  this,  or  the 
external  pudic  nerve,  to  be  the  seat  of  persistent  pain  concentrated 
there,  of  the  most  distressing  kind.  It  seems  as  if,  after  long  irritation 
of  the  nerves  involved,  pain  settles  in  a  particular  branch,  and  becomes 
difficult  to  dislodge,  even  after  the  disease  which  provoked  the  nervous 
trouble  had  ceased.  This  remark  applies  peculiarly  to  the  lumbar, 
dorsal,  and  sacral  aching  pain,  which  often  lasts  weeks  and  months  after 


442  M  E  T  E I T I S. 

the  uterus  has  been  restored  to  a  comparatively  healthy  condition.  In 
these  cases,  it  seems  highly  probable  that  the  long-continued  irritation 
of  the  lower  part  of  the  spinal  cord  has  induced  a  chronic  alteration  of 
nutrition.  This  lingering  ill  is  often  the  source  of  disappointment  and 
discouragement  to  patients  who  have  really  recovered  from  metritis. 
It  is  necessary  to  explain  that  effects  do  not  immediately  cease  after 
the  cause  is  removed ;  that  the  return  to  healthy  nervous  function,  to 
vigorous  muscular  power,  is  necessarily  gradual.  Muscles  long  dis- 
used have  fallen  away  ;  all  the  functions  exhibit  the  weakness  of 
structure  of  the  organs  which  execute  those  functions.  Healthy  tis- 
sues can  only  be  built  up  by  regulated  exercise  and  other  hygienic 
measures. 

A  not  uncommon  attendant  symptom  of  chronic  metritis  is  the 
"  Coccygodynia"  of  Simpson.  This  is  sometimes  so  distressing  that 
the  sufferer  cannot  sit  in  the  ordinary  way,  but  is  obliged  to  rest  upon 
one  or  other  ischium ;  and  some  women  on  this  account  constantly  use 
an  air-cushion.  Pain  is  often  felt  on  defecation.  Since  the  metritis  to 
which  this  pain  is  due,  itself  probably  arose  after  labor,  it  is  natural 
to  conjecture  that  the  sacro-coccygeal  joint  received  injury  during 
labor,  and  became  the  seat  of  chronic  inflammation.  In  some  in- 
stances this  is  really  the  case.  But  in  most  no  evidence,  beyond  the 
pain,  will  be  found  of  local  mischief.  It  is  a  form  of  neuralgia.  It 
is,  however,  desirable  to  determine  the  local  condition  by  examination. 
For  this,  the  forefinger  of  one  hand  is  passed  into  the  rectum,  whilst 
the  other  hand  feels  along  the  sacrum  or  down  the  joint  externally. 
In  this  way  the  joint  is  closely  approached  on  either  side,  and  the  rela- 
tion of  its  constituent  bones,  the  mobility  of  the  coccyx,  the  condition 
of  the  joint  can  be  accurately  made  out.  The  removal  of  this  sacro- 
coccygeal neuralgia  must  be  waited  for  in  the  same  way  as  the  subsi- 
dence of  other  nervous  disorders,  when  the  causing  disease  is  cured. 

A  nervous  affection  of  a  peculiarly  distressing  kind,  is  pruritus 
vagmce  et  vulvae.  This  is  not  an  uncommon  symptom  of  chronic  me- 
tritis. It  is  due  to  the  general  hypergesthesia  of  the  pelvic  nerves,  and, 
in  some  cases,  to  inflammation  of  the  mucous  membrane.  The  nervous 
filaments  distributed  in  the  papillee  being  involved,  of  course  present 
extensive  points  of  peripheral  irritation.  Where  there  is  inflammation 
of  the  mucous  membrane,  there  wnll  commonly  be  more  or  less  spas- 
modic contractility  of  the  vulva,  constituting  vaginismus.  But  an 
equal  degree  of  irritability  is  not  uncommon  where  there  is  no  local 
inflammation.  This  distressing  complication  is  sometimes  successfully 
treated  by  belladonna  or  morphia  pessaries.  But  the  only  effectual 
remedy  is  the  use  of  the  "  vaginal-rest." 

The  wear  and  tear  of  the  nervous  system,  and  the  degradation  of  the 
blood  attending  chronic  metritis,  hardly  ever  fail  to  bring  about  dis- 
turbance of  distant  parts.  This  is  manifested  in  various  sympathetic 
nervous  disorders.  One  of  the  most  frequent  is  facial  neuralgia.  The 
association  of  this  disorder  with  uterine  and  ovarian  trouble,  is  placed 
beyond  doubt  by  the  exacerbations  which  so  often  accompany  the  men- 
strual periods.  Hysteria  is  another  frequent  attendant.  Where  the 
disease  has  lasted  some  years,  being  prolonged  into  the  climacteric  age, 


METRITIS,  .  443 

the  nervous  disorders  characteristic  of  that  epoch  will  be  earlier  and 
more  strikingly  produced. 

A  symptom,  says  Peaslee,^  almost  pathognomonic  of  uterine  affec- 
tions, is  the  "  uterine  headache/'  referred  to  the  top  of  the  head,  usually 
extending  over  a  circular  or  oval  surface,  and  relieved  by  pressure. 
Sometimes  a  "crazy  feeling,"  a  sensation  of  cold  or  heat,  or  a  numb- 
ness is  complained  of,  or  the  surface  is  tender  on  pressure,  or  hot. 

The  Symptoms  and  Diagnosis. — The  disease  is  usually  so  protracted, 
coming  under  treatment,  perhaps,  long  after  its  earlier  stages  have 
been  passed  through,  that  it  is  difficult  to  gather  up  a  complete  orderly 
history  of  the  symptoms.  The  later  symptoms  will,  in  many  respects, 
differ  from  the  earlier  ones.  Still,  the  subjective  symptoms,  when  cor- 
rected and  complemented  by  the  objective  ones,  are  clear  enough  to 
mark  what  is  going  on. 

The  most  marked  symptom  is  acute  hypogastric  pain,  differing  from 
the  pains  of  retention  by  being  persistent,  and  becoming  more  intense. 
It  frequently  comes  on  suddenly,  with  initial  protracted  rigor.  Fever 
is  constant  in  acute  metritis,  and  not  rare  in  the  chronic  form.  Inflam- 
mation is  apt  to  spread  to  the  surrounding  organs,  and  if  the  peritoneum 
become  involved,  as  it  frequently  does,  the  pain  may  extend  from  the 
pelvis  to  the  abdomen.  The  patient  complains  of  a  feeling  of  burning 
heat  in  the  hypogastrium,  vagina,  and  vulva. 

On  examination,  the  vagina  feels  hot,  tense,  tumid  ;  pressing  the 
cervix  uteri  produces  acute  pain,  especially  if  so  pressed  as  to  move  the 
uterus.  Arterial  pulsations  may  be  felt  in  the  utero-vaginal  sinuses. 
The  uterus  is  felt  to  be  increased  in  bulk.  If  the  sound  be  introduced 
— and  this  ought  to  be  avoided  if  we  find  the  foregoing  signs  present — 
the  most  acute  pain  is  caused  by  the  passage  along  the  cervix,  and 
some  oozing  of  blood  is  very  likely  to  ensue. 

The  diagnosis,  indeed,  admits  of  being  perfectly  established  without 
the  sound.  The  state  of  the  uterus — perhaps  softened,  easily  bleeding, 
even  easily  penetrable  by  the  point  of  the  instrument — is  a  valid  rea- 
son for  not  using  it. 

The  pain  is  intensified  by  movement,  by  the  slightest  jar  or  shock, 
and  even  by  the  action  of  the  bowels  or  bladder.  If  acute  metritis 
attack  during  menstruation,  the  menstrual  flow  is  commonly  sup- 
pressed. In  the  chronic  form  it  may  also  be  suppressed;  but  some- 
times an  attack  of  menorrhagia  or  metrorrhagia  supervenes.  Dys- 
menorrhoea  is  almost  inevitable.  Suppression  of  menstruation  is  more 
characteristic  of  parenchymatous  metritis.  When  the  mucous  mem- 
brane is  principally  affected,  there  is  more  often  menorrhagia. 

Nausea  and  vomiting  are  hardly  ever  absent.  Bennet  looks  upon 
nausea  as  a  characteristic  symptom  of  parenchymatous  inflammation. 
The  active  engorgement  of  the  vessels  and  tissues  stretching  the  uterine 
fibre  accounts  for  this  symptom. 

The  "facies  uterina"  is  commonly  well  marked.  Sterility  is  almost 
constant  in  metritis.  In  the  acute  stage  pain  would  prevent  inter- 
course, and  in  the  slower  chronic  forms  the  altered  tissues  and  secre- 

1  American  Medical  Monthly,  1860. 


444  METRITIS. 

tions  are  unfavorable  to  conception,  and  to  the  retention  of  the  embryo 
in  the  rare  event  of  conception  taking  place. 

In  the  more  chronic  forms  of  metritis,  the  simple  vaginal  touch  may 
not  in  every  case  produce  pain.  If  the  surrounding  structures  be  not 
involved,  so  as  to  im])ede  the  mobility  of  the  uterus,  and  the  body  of 
the  organ  be  the  chief  seat  of  the  inflammation,  it  rises  and  retreats 
before  the  examining  finger,  so  that  the  tender  inflamed  part  escapes 
pressure.  But  when  we  combine  external  pressure  by  the  hand  above 
the  pubes,  pushing  the  fundus  down,  we  evoke  pain  by  bringing  the 
inflamed  part  under  compression. 

By  this  mode  of  examination  we  are  sure  to  bring  out  with  precision 
the  signs  of  disease  in  the  uterus;  and  by,  in  like  manner,  examining 
the  remaining  organs  in  the  pelvis,  we  may  exactly  trace  the  disease  to 
the  uterus. 

The  enlargement  of  the  uterus  which  always  attends  metritis,  chronic 
or  acute,  is  easily  determined  by  the  abdomino-vaginal,  or  the  recto- 
abdominal  touch.  The  fundus  of  the  uterus  in  acute  puerperal  me- 
tritis almost  invariably  rises  above  the  symphysis  pubis.  In  the  non- 
puerperal acute,  and  in  the  chronic  forms,  it  is  usually  not  difficult  to 
feel  the  fundus  by  pressing  the  fingers  a  little  firmly  behind  the  sym- 
physis, having  previously  emptied  the  bladder.  If  the  inflammation 
arise  out  of,  or  be  associated  with,  cancerous,  fibroid,  or  other  disease, 
the  enlargement  of  the  body  of  the  uterus  is  usually  greater,  and  the 
fundus  rises  proportionally  so  as  to  be  easily  reached. 

This  enlargement  of  the  uterus  imparts  some  degree  of  tumefaction 
to  the  lower  abdomen.  And  it  is  a  point  to  attract  attention,  that  the 
tumefaction  or  distension  of  the  abdomen  is  almost  always  much  greater 
than  the  mere  increase  in  size  of  the  uterus  can  account  for.  The  sur- 
plus is,  I  believe,  often  due  to  the  disturbance  in  the  state  of  the  intes- 
tines, which  the  neighboring  inflamed  organ  produces.  All  parts  in 
contact  with  an  inflamed  organ  are  constantly  disordered.  This  is 
especially  the  case  when  movement  is  a  necessary  condition  to  the  due 
performance  of  the  organs  implicated  by  proximity.  The  intestines 
are  in  this  case ;  and  they  appear  to  be  compelled  to  a  state  of  inaction 
or  paralysis,  in  order  to  spare  the  sensitive  inflamed  uterus.  Hence 
distension.     This  is  made  manifest  by  a  degree  of  tympanitis. 

So  long  as  the  inflammation  is  limited  to  the  uterus,  not  involving 
the  peritoneum  or  the  broad  ligaments,  the  uterus  remains  mobile.  If 
it  be  found  at  all  fixed,  we  may  conclude  that  the  inflammation  has 
extended  to  the  surrounding  structures.  Although  in  a  large  propor- 
tion of  the  cases  of  chronic  metritis  the  uterus  retains  its  mobility,  we 
must  always  be  prepared  for  extension  of  inflammation  to  the  neigh- 
boring parts.  When  this  occurs,  as  it  may  do  under  the  influence  of 
cold,  overexertion  or  violence,  especially  if  encountered  during  a  men- 
strual period,  there  will  be  exacerbation  of  pain,  and  this  more  widely 
spread ;  and  there  will  be  some  febrile  excitement. 

Metritis  may  be  mistaken  for  congestion,  flexion,  uterine  tumor,  or 
perimetric  disease.  I  do  not  here  stop  to  point  out  the  special  means 
of  diagnosis,  because  these  will  be  discussed  when  describing  these 
several  disorders. 


METRITIS.  445 

In  simple  congestion,  fever  is  usually  absent.  There  is  not  the  burn- 
ing heat  in  the  vagina,  nor  the  same  degree  of  tenderness  of  the  uterus. 

The  duration  of  acute  parenchymatous  metritis,  if  not  complicated 
with  septic  conditions,  or  perimetritis,  is  generally  from  three  weeks  to 
a  month.     The  usual  termination  is  in  resolution. 

But  in  patients  who  have  neglected  care,  rest,  and  appropriate  treat- 
ment, and  especially  in  those  who  are  the  subjects  of  strumous  or  other 
morbid  diathesis,  or  who  are  simply  of  weak  constitution,  the  inflam- 
mation merges  into  the  chronic  form,  and  is  not  unlikely  to  spread  to 
neighboring  structures. 

Perimetritis,  or  inflammation  of  the  peritoneal  investment  of  the 
uterus,  will  be  more  conveniently  described  in  connection  with  pelvic 
cellulitis  and  pelvic  peritonitis  in  a  subsequent  chapter. 

The  Curability  of  Meti'itis,  Acute  and  Chronic. — There  can  be  no 
doubt  in  the  mind  of  those  who  have  had  large  opportunities  of  observ- 
ing puerperal  diseases,  that  acute  and  even  subacute  metritis  is  often 
followed  by  substantial,  if  not  complete,  recovery.  We  cannot  avoid 
this  conclusion,  if  we  accept  as  evidence  of  restoration  the  return  to 
healthy  functional  activity.  Who  has  not  known  women  who  have 
suffered  metritis  after  labor  or  abortion,  subsequently  menstruate  easily, 
become  pregnant,  go  through  labor,  lactation,  and  resume  the  duties  of 
life  with  comfort?  It  is  scarcely  possible  that  a  history  such  as  this 
should  be  frequent,  if  any  decided  uterine  disease  persisted. 

The  case  is  somewhat  different,  however,  with  chronic  metritis.  Slow 
changes  of  tissue,  continuing  over  months  and  years,  are  with  difificulty 
counteracted.  Still,  appealing  to  the  same  evidence  which  proves  the 
cure  of  acute  metritis,  we  cannot  absolutely  deny  the  curability  of 
chronic  metritis.  Pregnancy  is  assuredly,  if  I  may  trust  my  own  ob- 
servation, not  infrequent.  It  sometimes,  no  doubt,  takes  place  whilst 
the  uterus  is  still  in  an  imperfectly  restored  condition.  But  the  value 
of  this  test  of  return  to  functional  work  is  strong.  I  think  this  fact 
should  qualify  the  discouraging  conclusion  of  Scanzoni  that,  perhaps, 
with  the  exception  of  some  extraordinarily  rare  instances,  it  is  not  in 
the  power  of  the  physician  so  to  cause  the  tissue-changes  of  chronic 
metritis  to  disappear,  that  the  uterus  is  completely  brought  back  to  its 
normal  condition.  When  once  the  process  of  hypertrophic  induration 
with  condensation  of  tissue  has  been  accomplished,  it  is  certainly  con- 
trary to  experience  to  find  that,  either  by  internal  remedies  or  by  local 
applications,  we  can  reverse  the  process  which  has  taken  place,  cause 
the  new  material  to  be  absorbed,  and  restore  the  uterus  to  its  pristine 
condition.  We  have  the  clearest  evidence  of  the  permanent  character 
of  the  tissue-changes  wrought  by  chronic  metritis  brought  directly 
under  our  senses  in  the  chronic  hypertrophic  elongation  of  the  cervix. 
Growth  with  induration  having  taken  place,  it  may  be  confidently  said 
that  nothing  short  of  surgical  agency  will  remove  the  disease.  It  may 
by  analogy  be  contended  that  like  changes  in  the  body  of  the  uterus 
will  be  equally  permanent.  Although  this  part  is  liable  to  similar 
tissue-changes,  still  this  does  not  appear  to  be  so  frequent.  Now  if,  as 
Scanzoni  himself  asserts,  there  is  no  such  thing  as  chronic  metritis 
absolutely  limited  to  one  part  of  the  organ,  of  course  when  we  have 


446  METRITIS. 

hypertrophic  induration  of  the  cervix,  about  which  there  can  be  no 
doubt,  before  us,  we  must  infer  that  the  body  of  the  uterus  is  similarly 
affected.  Xow,  it  is  a  fact  beyond  dispute  that  pregnancy  is  not  uncom- 
mon in  cases  of  very  advanced,  even  extreme,  hypertrophic  elongation 
of  the  cervix.  I  have  notes  of  many  such  cases.  We  are  driven,  then, 
to  conclude  that  the  hypertrophy  resulting  from  chronic  metritis  may 
either  be  so  far  cured  that  the  uterus  can  resume  its  highest  function, 
or  that  the  persistence  of  the  hypertrophic  change  is  not  an  absolute 
bar  to  this  resumption  of  function.  Practically,  whichever  alternative 
we  adopt,  there  is  a  cure. 

This  brings  us  to  another  question  of  great  practical  interest.  What 
is  the  influence  of  pregnancy  in  curing  chronic  metritis  and  its  results? 
If  we  assume  that  all  must  be  cured  before  gestation  can  go  on,  of  course 
the  question  falls  to  the  ground.  But  if,  on  the  other  hand,  we  assume 
that  conception  may  take  place  and  gestation  proceed  to  term,  in  an 
organ  which  is  the  seat  of  chronic  metritis  and  its  results,  what  will  be 
the  effect  upon  the  disease?  Speaking  from  clinical  observation  and 
analogical  reasoning,  I  feel  confident  that,  under  this  condition,  a  cure 
may  be  effected,  that  is,  that  the  new  hypertrophied  tissue  may  be  re- 
moved, and  the  uterus  brought  back  to  its  pristine  state,  or  nearly  so. 
Instances  have  come  under  my  observation  as  well  as  under  that  of 
others,  proving  that  fibroid  tumors  have  been  dispersed  by  absorption — 
I  do  not  mean  by  sloughing  or  by  casting  off  in  mass,  more  common 
events — under  the  influence  of  pregnancy.  These  tumors,  composed 
of  tissue,  not  dissimilar  from  that  of  the  morbid  hypertrophic  element, 
are  caught  in  the  involution-process,  which  reduces  the  normal  hyj^er- 
trophic  element,  and  like  it,  they  vanish.  Is  it  not  in  the  highest  de- 
gree probable  that  the  new  hypertrophic  matter,  uniformly  distributed 
in  the  midst  of  the  proper  uterine  tissue,  may  be  equally  caught  in  this 
absorption-process,  and  be  thus  removed?  I  believe  I  have  seen  dis- 
tinct diminution  in  bulk  of  the  hypertrophied  cervix  follow  upon  labor. 
I  think,  then,  we  may  conclude  that  the  uterus  hypertrophied  under 
chronic  metritis  may  be  restored,  at  least,  sufficiently  for  the  resump- 
tion of  its  duty.  If  the  morbid  hypertrophic  matter  can  be  removed 
by  gestation,  why  not  by  other  means?  I  do  not  pretend  that  other 
means  at  our  disposal  are  of  equal  efficacy  wdth  pregnancy.  But  if  we 
can  establish  a  reasonable  presumption  that  the  condition  is  curable  by 
any  means,  surely  we  need  not  despair  of  finding  other  means  that  may 
accomplish  the  same  end. 

Again,  uterine  fibroids  occasionally  undergo  a  process  of  degenera- 
tion or  atrophy,  the  senile  involution,  after  the  climacteric.  The  proper 
uterine  tissue  itself  undergoes  this  atrophic  involution.  Why  should 
not  the  abnormal  hypertrophic  tissue  undergo  the  like  change?  As  a 
rule  new  formations  are  more  ready  to  undergo  atrophy  by  absorption 
or  degeneration  than  healthy  tissue ;  and,  as  a  matter  of  observation,  I 
think  I  shall  be  supported  when  I  affirm  that  hypertrophic  indm-ation, 
the  result  of  chronic  metritis,  does  undergo  atrophy  under  this  condi- 
tion. 

It  is  in  accordance  with  general  opinion  that  active  inflammatory 
process  of  the  uterus  and  ovaries  tends  to  spontaneous  remission  and 


METRITIS.  447 

cure  at  tlie  climacteric  period.  Ceasing  to  be  stimulated  by  the  periodi- 
cal liypersemia  of  ovulation,  the  local  inflammation  naturally  subsides. 
But  we  must  not  hastily  conclude  that  uterine  disease  will  always  un- 
dergo spontaneous  cure  or  alleviation  at  this  period.  In  many  cases 
the  disease  continues,  often  attended  with  hemorrhage.  The  morbid 
action,  once  set  going,  is  maintained  by  the  hyperemia  of  obstructed 
venous  circulation,  and  by  the  disposition  to  local  hsemostasis  so  com- 
mon at  this  period  of  life.  And  there  seems  to  be  also  a  more  or  less 
persistent  ovulation-efFort  going  on,  in  many  cases,  for  years  after  the 
climactei'ic  has,  according  to  all  presumption,  arrived. 

Scanzoni  urges  many  reasons  why  sterility  is  the  doom  of  women 
suiFering  from  chronic  metritis.  1.  There  is  the  accumulation  of  more 
or  less  unhealthy  secretion.  2.  Premising  that  the  shedding  of  the 
mucous  membrane  itself  is  much  more  common  than  is  generally 
thought,  he  says  he  has  never  known  a  case  in  which  considerable 
fragments  of  mucous  membrane  having  been  regularly  cast  at  each 
menstruation  the  woman  has  conceived.  The  membrane  is  cast  just  at 
the  end  of  the  period,  the  very  moment  when  the  impregnated  ovum 
wants  a  decidua  to  attach  itself  to.  3.  The  ovaries  are  frequently  im- 
plicated in  chronic  metritis.  4.  There  is  pain  or  indifference  attending 
the  sexual  act. 

Certainly  sterility  is  a  frequent  consequence,  but  it  is  far  from  uni- 
versal. Scanzoni  himself  admits  that  pregnancy  may  occur,  and  he 
rightly  says  that  its  course  is  generally  unfavorably  affected  by  the 
morbid  state  of  the  uterus. 

Can  the  so-called  benign  tumefactions  caused  by  chronic  hyperemia 
and  inflammation  pass  into  cancerous  degeneration?  This  is  another 
question  often  anxiously  put. 

The  treatment  of  acute  metritis  will  be  governed  by  the  opinion  we 
may  form  as  to  whether  the  case  is  one  of  metritis  simple,  or  of  metritis 
complicated  with  septic  infection.  In  the  former  case  the  treatment 
will  be  more  purely  antiphlogistic.  Twelve  to  twenty  leeches  may  be 
usefully  applied  above  the  pubes.  Aran  and  most  French  physicians 
advise  six  or  eight  leeches  to  the  cervix  uteri.  Fomentations  give  re- 
lief. A  pasma  consisting  of  one  drachm  of  extract  of  belladonna  mixed 
with  half  an  ounce  of  mild  blue  ointment  and  two  ounces  of  simple 
cerate,  spread  in  a  thin  layer  on  a  piece  of  lint,  and  applied  to  the  hypo- 
gastric region,  the  whole  covered  over  with  a  light  packing  of  cotton- 
wool, will  not  only  give  ease,  but  be  of  material  use  in  subduing  the 
inflammation.  Experience  has  proved  the  importance  of  completely 
securing  the  surface  covering  inflamed  organs  from  contact  with  the 
air.  It  is  by  acting  in  this  way  that  the  cotton-w^ool  packing  undoubt- 
edly does  good. 

It  is  desirable  to  unload  the  rectum  of  any  fecal  accumulation  by  an 
enema.  But  this  done,  it  is  not  advisable  to  disturb  the  inflamed  parts 
by  purging  until  the  acute  stage  is  past.  When  the  stage  of  resolution 
is  advanced,  purgatives  are  very  useful.  Piillna  or  Friederickshall 
waters  are  excellent  forms. 

Tepid  vaginal  irrigations  with  water  or  decoction  of  poppyheads,  or 
with  a  little  laudanum,  are  useful. 


448  METRITIS. 

Salines,  especially  the  acetate  of  ammonia  and  nitrate  of  potash  com- 
bined with  sedatives,  constitute  the  best  internal  remedies. 

It  is  needless  to  add  that  absolute  rest  is  the  essential  condition  of 
successful  treatment  in  the  more  acute  forms  of  the  affection.  Precau- 
tion is  especially  necessary  when  the  menstrual  epoch  is  approaching. 

When  there  is  septic  complication,  leeching  must  be  avoided.  The 
mercurial  belladonna  ointment  may,  however,  still  be  useful.  Salines 
must  be  early  combined  with,  or  give  place  to  bark,  quinine,  and  gen- 
eral tonic  treatment. 

The  discharges  should  be  carefully  examined.  If  they  be  in  any 
degree  oifensive,  tepid  intra-uterine  injections  of  weak  solution  of  per- 
manganate of  potash  should  be  used.  Septicaemia  is  kept  up  by  the 
continuous  or  intermittent  imbibition  into  the  vascular  system  of  fresh 
doses  of  septic  matter.  The  system  may  frequently  be  able  to  throw 
off  a  moderate  amount  of  the  poisonous  element,  and  the  local  inflam- 
mation as  well  as  the  general  disturbance  may  soon  subside  if  the  re- 
newal of  the  irritating  cause  be  prevented. 

The  treatment  of  chronic  metriiis  is  conducted  essentially  on  the  same 
principles  as  that  of  arrested  involution.  The  first  question  to  decide 
is  as  to  the  application  of  what  is  called  antiphlogistic  treatment. 

Upon  the  usefulness  of  local  abstraction  of  blood,  opinions  are  very 
much  divided.  The  indication  seems  clear  to  relieve  the  local  hypersemia 
which  is  so  essentially  concerned  in  the  genesis  and  maintenance  of  the 
disease.  And  I  am  willing  to  admit  that  great  ease  is  often  felt  by 
patients  after  leeching  the  cervix  uteri.  But  it  has  appeared  to  .me 
that  this  benefit  is  chiefly  experienced  when  the  disease  is  in  the  early 
or  subacute  stage,  that  is,  during  Scanzoni's  first  stage  of  infiltration. 
When  induration  has  set  in,  I  believe  not  much  good  is  to  be  expected 
from  bleeding.  And  the  indication  to  relieve  the  tension  of  the  local 
circulation  may  often  be  greatly  met  by  supporting  the  loaded  organ 
at  its  proper  level  by  a  lever  or  other  suitable  pessary.  This  contri- 
vance will  often  not  only  facilitate  the  return  of  blood  by  the  veins, 
but  it  also,  by  nursing  the  uterus,  as  it  were,  secures  a  degree  of  rest 
which  is  essential  to  cure.  There  is  always  some  degree  of  prolapsus, 
if  not  of  version  or  flexion,  which  involves  more  or  less  strangulation 
of  the  vessels  at  the  point  of  their  entry  and  exit.  If  this  sinking  or 
displacement  be  counteracted,  one  great  cause  of  the  maintenance  of  the 
disease  is  j3ro  tanto  mitigated.  This  mechanical  support  will  be  useful 
chiefly  in  the  earlier  stages,  but  it  will  be  of  service  at  times  all  through. 
One  great  recommendation  of  it,  is  that  it  renders  "  lying  down"  less 
necessary.  I  am  sure  that  in  many  cases  a  woman  will  obtain  more 
effectual  ''rest"  for  the  uterus,  by  a  properly  adapted  pessary,  whilst 
taking  a  moderate  ampunt  of  exercise,  than  she  will  by  rigorous  "lying 
down"  without  it. 

If,  therefore,  leeches  be  employed,  it  will  be  wise  to  watch  the  effect 
well,  and  not  to  repeat  them  unless  we  are  well  assured  that  they  do 
what  is  wanted  of  them  by  relieving  gorged  vessels. 

It  is  well  to  remember — I  do  not  mention  this  as  an  objection  to  the 
proper  use  of  leeches — that  more  or  less  troublesome  events  may  attend 
their  use.     1st,  a  leech  may  make  its  way  into  the  cervical  canal  and 


TREATMENT.  449 

bite  there;  the  pain  is  generally  excruciating.  To  avoid  this  it  is  M^ell 
to  insert  a  small  plug  of  lint  in  the  os  uteri,  if  this  be  patulous.  2d, 
the  bleeding  may  be  too  profuse.  To  stop  this,  it  ^vill  usually  be 
enough  to  wipe  off  the  congealed  blood  so  as  to  expose  the  bite,  and  to 
apply  to  it  a  small  compress  steeped  in  a  styptic  solution  of  perchloride 
or  persulphate  of  iron.  If  the  bleeding  break  out  some  time  after  the 
leeches  have  been  withdrawn,  and  the  patient  has  been  left,  the  same 
course  is  still  the  best.  Get  at  the  wound,  and  apply  the  styptic  to  it 
direct.  As  a  temporizing  measure  we  may  sometimes  apply  first  one 
plug  soaked  in  a  strong  solution  of  alum,  carrying  this  up  to  the  fundus 
of  the  vagina,  and  then  a  succession  of  other  plugs  of  lint  lightly  lubri- 
cated with  oil,  so  as  to  exert  compression.  3d,  sometimes  the  most 
agonizing  pain  follows  the  bleeding.  This  may  be  allayed  by  opium 
by  the  mouth,  or  by  an  opiate  lotion,  or  by  a  narcotic  pessary. 

Scanzoni,  who  is  a  strenuous  advocate  for  leeching,  signalizes  another 
consequence.  He  describes  a  peculiar  erythema  or  urticaria,  which 
comes  on  a  few  minutes  after  the  leeches  have  taken.  A  shudder  or 
even  a  rigor  is  followed  by  swimming  in  the  head,  disorder  of  the 
senses,  even  delirium.     Then  the  urticaria  blebs  come  out. 

Leeches  should  not  be  applied  when  tliere  is  marked  ansemia ;  when 
the  signs  of  acute  hypersemia  are  not  present ;  when  the  disease  is  of 
long  standing,  and  the  induration  process  has  made  way. 

Warmth  is  of  the  greatest  service  in  the  treatment  of  chronic  metritis. 
When  there  is  an  exacerbation  of  pain  from  fatigue  or  exposure,  heat 
may  be  applied  dry,  by  heated  bags  of  salt  or  bran  to  the  hypogas- 
trium.  But  in  almost  every  stage,  warmth,  combined  with  moisture, 
renders  eminent  service.  The  whole  bath  at  a  temperature  of  90°  to  95° 
F.  is  perhaps  the  best  method  of  applying  it.  It  acts  in  a  twofold  man- 
ner. It  exerts  a  not  unimportant  resolutive  influence  upon  the  gorged, 
loaded  uterus. .  Not  that  any  marked  power  can  be  proved  in  promoting 
absorption  when  the  organ  has  become  hypertrophied  and  indurated. 
But  in  the  earliest  stages,  there  seems  reason  to  believe  that  warm  mois- 
ture may  aid  in  relieving  congestion.  No  one  doubts  the  beneficial 
soothing  action  of  hot  fomentations  on  superficial  phlegmasia.  A 
similar  action  can  be  exerted  on  the  uterus.  Secondly,  warm  baths  are 
useful  in  promoting  a  healthy  secreting  action  of  the  skin ;  and  this  is 
an  essential  condition  of  the  relief  of  internal  hypersemic  processes. 

The  hip-bath  may  often  be  conveniently  substituted  for  the  whole 
bath,  although  it  is  open  to  the  objection  that  it  compels  an  uncomfort- 
able position. 

To  get  the  full  benefit  from  warm  baths,  it  is  necessary  to  give  the 
water  free  access  to  the  vagina.  This  can  be  accomplished  by  the  use 
of  the  bath-speculum.  The  most  convenient  form  is  a  conical  one,  with 
a  very  wide  inferior  opening.  The  cone — the  part  introduced  into  the 
vagina — is  perforated  with  holes  the  size  of  a  sixpence.  The  patient 
can  easily  apply  it. 

In  many  cases,  the  value  of  warm  baths  is  enhanced  by  the  addition 
of  various  medicinal  substances.  Amongst  those  I  have  found  the 
most  useful  are  Vichy  salts,  or  the  Woodhall  Spa  waters.  Gallard, 
however,  cautious  against  the  prolonged  use  of  Vichy  or  other  alka- 

29 


450  METRITIS. 

line  or  mineral  waters.  He  advises,  in  preference,  more  simply  ther- 
mal springs,  as  Plombieres. 

The  general  treatment  should  be  sustaining  and  tonic.  Iodine,  iron, 
strychnine,  quinine,  and  arsenic,  become  entirely  useful  when  active 
inflammatory  conditions  have  been  subdued. 

Of  late  years,  so-called  resolutive  pessaries  of  iodine,  made  up  into 
conical  balls,  with  cocoanut  butter  or  other  ingredients,  have  been 
largely  used.  Most  patients  find  it  troublesome,  if  not  difficult,  to 
apply  them  properly ;  often,  whether  from  being  badly  made  or  other 
causes,  they  fail  to  melt  down  in  situ  as  desired ;  and,  not  seldom,  they 
are  a  source  of  so  much  irritation  that  they  have  to  be  given  up. 

I  have,  for  some  time  past,  found  it  better  to  introduce  into  the 
cervical  canal,  or  into  the  cavity  of  the  uterus,  some  weak  iodine  oint- 
ment by  means  of  the  instrument  figured  at  p.  129,  Fig.  44. 

The  subject  of  intra-uterine  medication  will  be  more  fully  discussed 
when  dealing  with  Endometritis. 

Since  intra-uterine  medication  can  only  be  carried  out  by  the  physi- 
cian, and  as  it  is  essential  to  apply  iodine  frequently,  the  method  of 
Scanzoni  can  be  employed  at  the  same  time.  This  consists  in  intro- 
ducing, by  means  of  a  small  bath-speculum,  a  drachm  of  iodide  of 
potassium  in  an  ounce  of  glycerin  to  the  fundus  of  the  vagina,  keep- 
ing it  there  all  night.  A  better  plan  is  to  apply  a  pledget  of  cotton- 
wool soaked  in  the  iodized  glycerin  by  means  of  the  speculum  figured 
at  p.  131. 

C.  Mayer  speaks  highly  of  the  value  of  pyroligneous  acid  in  treat- 
ing the  bleeding  papillary  affections  of  the  os  uteri  and  cervical  canal. 
He  says  there  is  no  more  efficacious  means.  He  applies  it  either  alone 
or  with  equal  parts  of  aqua  creasoti,  through  the  speculum.  It  is  left 
in  contact  long  enough  to  stop  the  bleeding,  and  until  the  abraded  spot 
assumes  a  white  appearance.     It  is  then  washed  away  by  a  syringe. 

Amongst  the  most  effective  measures  for  substituting  a  healthy  for 
the  morbid  nutritive  process  going  on,  and  of  promoting  absorption  of 
morbid  tissue,  are  the  various  forms  of  cautery,  actual  and  potential. 
The  actual  cautery  was  extensively  used  by  the  late  M.  Jobert.  It 
was  in  the  clinique  of  St.  Louis  that  I  first  became  acquainted  with 
its  action  and  use.  I  think  it  would  have  become  more  firmly  estab- 
lished as  a  resource  in  the  treatment  of  the  results  of  chronic  metritis, 
were  it  not  for  the  natural  deterrent  influence  of  fear  lest  so  potent  an 
agent  may  do  harm,  and  the  formidable  preparations  which  the  use  of 
the  hot  iron  involves. 

The  following  precautions  are  necessary  when  applying  the  incan- 
descent iron  to  the  vaginal-portion  :  1.  To  use  a  horn  speculum,  which 
is  less  heat-conducting  than  metal;  or  else,  if  using  a  metal  speculum, 
to  interpose  a  packing  of  lint  outside  the  blades,  so  as  to  protect  the 
vagina.  2.  To  be  careful  to  have  nothing  in  the  field  of  the  speculum 
but  the  vaginal-portion,  so  that  no  risk  be  run  of  cauterizing  the 
vagina.  3.  To  apply  the  cautery  to  the  outer  edge  of  the  os  uteri, 
avoiding  the  cervical  cavity. 

The  galvano-caustic  apparatus  would  always  be  used  in  preference 
to  the  heated  iron,  were  it  not  so  cumbersome  and  inconvenient  in 


TREATMENT.  4^1 

preparation.  It  admits  more  easily  of  precision ;  the  point  which 
carries  the  heat  can  be  adjusted  when  cold  to  the  spot  to  be  burned, 
and  being  thus  deliberately  and  accurately  applied,  the  heat  is  then 
turned  on,  and  maintained  as  desired ;  it  is  even  possible  to  shift  the 
cautery  to  diiFerent  parts  of  the  morbid  surface,  and  by  turning  off  the 
heat,  as  may  be  done  at  will  by  breaking  the  galvanic  current,  the  in- 
strument can  be  removed  without  danger  of  burning  more  than  is 
desired.  It  also  possesses  the  great  advantage  of  being  worked  with 
a  much  shorter  handle  than  is  necessary  with  the  heated  iron,  so  that 
both  hand  and  eye  can  be  brought  nearer  to  the  seat  of  operation,  and 
work  w^ith  more  exact  command. 

The  best  substitute  for  the  actual  cautery  is  the  potential  cautery. 
Various  caustics  have  been  used.  They  all  act  substantially  in  the 
same  way.  By  chemical  action  they  kill  a  portion  of  tissue,  which  is 
thrown  oflP  as  a  slough  or  eschar,  leaving  a  sore  which  has  to  heal  by 
granulation.  During  this  healing,  some  amount  of  absorptive  action 
is  set  up  in  the  proximate  tissues ;  and  the  healing  taking  place  by 
cicatrix,  further  diminution  of  bulk  is  effected  by  the  contraction. 

The  substances  most  employed  are, — the  acid  nitrate  of  mercury  : 
this  is  very  convenient  and  effective ;  potassa  cum  calce  fused  in  sticks  : 
this  is  the  most  convenient  and  generally  useful  caustic  with  which  I 
am  acquainted;  it  was  recommended  to  me  by  Dr.  Henry  Bennet.  It 
differs  from  the  acid  caustics,  such  as  nitric,  chromic,  and  sulphuric 
acids,  which,  absorbing  moisture  rapidly,  and  coagulating  albumen, 
produce  only  a  superficial  slough.  Potash  also  has  a  great  affinity  for 
water ;  but  not  possessing  the  property  of  coagulating  albumen,  it  is 
carried  more  deeply  into  the  substance  of  the  part  to  which  it  is  ap- 
plied. Herein  consists  the  advantage  it  possesses.  Upon  this  pene- 
tration it  is  that  the  absorptive  action  it  sets  up  depends. 

The  time  selected  for  applying  it  should  be  within  a  few  days  after 
the  termination  of  a  menstrual  period,  so  as  to  secure  ten  days  or  more 
for  the  granulating  process  to  go  on  undisturbed  by  the  menstrual  flux. 

The  mode  of  using  it  is  to  introduce  the  speculum  so  as  to  get  the 
vaginal-portion  well  into  the  field ;  to  wipe  off  all  adhering  secretion  ; 
then,  holding  a  small  piece  of  the  potassa  cum  calce  in  a  long  speculum- 
forceps,  to  rub  it  across  one  or  both  lips  of  the  os  uteri  several  times. 
This  produces  a  blackish  bar.  Care  should  be  taken  not  to  touch  be- 
yond the  hard  substance  of  the  cervix,  avoiding  the  vagina.  When  a 
sufficient  application  has  been  made,  a  pledget  of  cotton-wool  steeped 
in  vinegar  is  immediately  applied  to  the  part.  This,  neutralizing  any 
remains  of  the  caustic,  obviates  extension  of  its  action  to  the  vagina. 
A  bit  of  string  attached  to  the  wool,  enables  the  patient  to  withdraw 
it,  which  may  be  done  in  a  few  hours. 

After  such  an  application  no  further  local  treatment  is  necessary 
until  after  the  lapse  of  ten  days.  The  granulating  surface  may  then 
be  lightly  touched  with  nitrate  of  silver. 

At  one  time  a  very  favorite  remedy,  one  employed,  it  is  true,  with- 
out precise  diagnosis  of  metritis,  was  blistering  by  tartar-emetic  oint- 
ment.    By  rubbing  this  substance  over  the  groins  or  hypogastrium. 


452  METRITIS. 

or  inside  the  thighs,  a  revulsive  action  is  produced,  which  is  sometimes 
serviceable. 

It  has  been  recommended  to  establish  a  seton  in  the  vaginal-portion 
as  a  derivative  and  resolutive.  I  have  not  put  this  to  the  test ;  but  I 
can  quite  understand  that  it  may  act  beneficially.  The  potassa  cum 
calce,  however,  answers  the  same  indication. 

Dr.  Robert  Johns  recommended  as  a  derivative  the  establishment  of 
a  blister  on  the  cervix  uteri  by  the  application  of  blistering  fluid.  I 
very  much  prefer  the  application  of  potassa  cum  calce  or  the  actual 
cautery.  Far  less  irritation  is  caused ;  and  the  small  eschar  falling 
leaves  a  healthy  sore  which  must  heal  by  granulation.  This  process 
usually  sets  up  an  absorptive  action  in  the  neighboring  infiltrated  tis- 
sues. And  when  the  sore  is  healed,  almost  always  something  is  gained 
in  the  diminished  bulk  and  lessened  hyperemia.  The  cautery,  poten- 
tial or  actual,  should  not  be  employed  whilst  there  is  any  degree  of 
active  inflammation.  It  comes  in  most  beneficially  when  vascularity 
is  subdued,  where  there  is  a  languid  process  of  tissue-change  going  on. 

Laxatives  become  important  in  chronic  metritis.  The  compound 
decoction  of  aloes,  or  lenitive  electuary,  are  useful  forms.  But  I  have 
found  the  greatest  benefit  from  the  daily  or  occasional  use  of  a  pill 
containing  two  grains  of  watery  extract  of  aloes,  half  a  grain  of  extract 
of  belladonna,  half  a  grain  of  extract  of  nux  vomica  with  Castile  soap. 

Scanzoni  speaks  emphatically  against  the  plan  of  enforcing  the 
^'repos  absolu,''  that  is,  "  lying-down,"  as  one  of  the  most  serious  errors 
that  can  be  committed.  I  have  seen  so  much  evil  from  this  course, 
and  have  seen  so  many  M^omen  who  had  been  kept  for  months  in  the 
recumbent  posture,  not  only  without  benefit,  but  with  decided  detri- 
ment, get  well  quickly  when  subjected  to  a  more  liberal  treatment,  that 
I  heartily  indorse  Scanzoni's  conclusion. 

Scanzoni  says  the  Friedrickshall,  Piillna,  Kissingen,  Ems,  Carlsbad, 
and  the  other  waters,  act  only  on  the  diseased  uterus  through  their 
virtue  as  purgatives. 

In  all  chronic  uterine  diseases  the  habitat  becomes  an  important 
matter.  Women,  far  more  than  men,  especially  when  invalids,  are 
"  adscriptse  glebse."  If  the  soil  be  damp,  or  other  hygienic  conditions 
be  unfavorable,  women  suffer  seriously,  and  often  in  such  a  degree  as 
to  frustrate  the  best-directed  medical  treatment.  Change  of  air,  then, 
which  means  change  of  soil,  is  often  essential  to  recovery.  A  dry  ele- 
vated site  is  generally  the  most  suitable. 

The  restorative  treatment  comes  into  use  when  the  local  disease  has 
subsided,  at  least,  in  part.  Iron  is  usually  badly  borne  whilst  inflam- 
mation, no  matter  how  slight,  is  going  on.  The  way  must  also  be 
prepared  by  salines,  laxatives,  bismuth,  and  other  agents  which  regu- 
late and  allay  all  irritation  of  the  stomach. 

Ulcerative  Processes^ 

Besides  the  uterine  abscesses,  the  result  of  acute  metritis,  the  cancer- 
ous and  tuberculous  ulcerations,  and  the  puerperal  suppurations,  ulcers 
occur  on  the  vaginal-portion. 


ENDOMETRITIS.  453 

In  the  course  of  uterine  and  vaginal  catarrh  there  arise  excoriations 
or  abrasions  of  a  stellate  or  annular  form  around  the  os  externum  which 
commonly  extend  into  the  cervical  canal.  These  at  times  pass  into 
erosions  and  ulcerations  marked  by  papillary  granulations,  of  a  fungoid 
aspect,  or  tlie  surface  is  tuberous  through  the  exuberant  development 
of  ovula  Nabothi.  The  origin  and  persistence  of  this  state  is  favored 
by  hypertrophy,  hypersemia,  and  varicosity  of  the  vessels  of  the  vaginal- 
portion. 

The  so-called  phagedenic  ulcer,  the  corroding  ulcer  of  Charles  M. 
Clarke,  of  the  os  uteri,  is  very  rare.  Its  existence  otherwise  than  as  a 
stage  of  cancroid  or  cancer  is  questioned.  But  I  believe  I  have  seen 
it  as  an  indented  hollowed  ulcer  on  a  hypertrophied,  hard,  callous 
vaginal-portion,  eating  away  the  cervix  uteri,  and  seizing  upon  the 
neighboring  structures,  in  a  manner  very  similar  to  that  of  lupus 
exedens. 

The  syphilitic  ulcer  possessing  the  proper  characters  of  the  primary 
chancre  is  not  common ;  but  it  may  at  times  be  observed  exhibiting  a 
closely  similar  aspect  to  that  which  is  seen  on  the  penis,  and  producing 
in  like  manner  sores  more  or  less  sharply  defined  on  the  vaginal  dupli- 
cature  which  lies  in  contact  with  the  cervix  uteri.  On  examining  by 
the  finger,  the  sharply-defined  edge  of  the  syphilitic  sore  may  at  first  im- 
pose on  the  sense  of  touch  for  the  os  uteri,  the  pit  or  depression  formed 
in  the  fundus  of  the  vagina  is  so  distinct. 

Endometritis :   Uterine  Catarrh. 

Inflammation  may  be  more  or  less  limited  to  the  lining  membrane, 
constituting  endometritis.  This  may  take  its  rise  in  childbirth ;  and 
it  may  be  general,  or  chiefly  restricted  to  the  original  seat  of  the  pla- 
centa. The  placental  seat  remains  rough,  presenting  papillary  projec- 
tions ;  perhaps  one  may  be  large  enough  to  deserve  the  name  of  a 
polypus. 

In  the  case  of  endometritis  proper,  the  uterine  contraction  after 
labor  has  been  efficient,  so  as  to  prevent  the  entrance  of  septic  matter 
into  the  venous  channels  and  lymphatics,  and  thus  to  obviate  metritis. 

Where  the  constitution  is  sound,  free  from  morbid  diathesis,  endo- 
metritis, treated  early,  admits  of  easy  cure.  Rest  alone  may  be  suffi- 
cient. The  regenerative  power  of  the  uterine  mucous  membrane  is  so 
active,  that  the  degenerated  tissue  being  cast  off  a  new  sound  one  is 
easily  formed.  But  if  there  be  a  morbid  diathesis,  as  strumous,  tuber- 
cular or  syphilitic,  the  cure  may  be  indefinitely  protracted.  The  mu- 
cous membrane  of  the  uterus  and  its  glands  are  not  less  prone  to 
receive  the  stamp  of  these  diatheses  than  is  the  mucous  membrane  of 
other  organs.  The  strumous  mucous  membrane  of  the  uterus  is  tumid, 
undergoing  constant  epithelial  shedding,  its  glands  are  hypertrophied, 
and  secrete  an  excess  of  mucus.  This,  in  fact,  is  one  of  the  most 
troublesome  forms  of  uterine  catarrh. 

Chronic  endometritis  leads  to  the  exuberant  production  of  ovula 
^abothi  in  the  cervix  and  on  the  vaginal-portion.  Indeed,  Lance- 
reaux  has  designated  this  as  "  cystic  metritis."     In  some  cases  the  cer- 


454  ENDOMETRITIS. 

vix  is  virtually  closed  by  a  collection  of  cysts  disposed  in  a  loculated 
stroma,  and  containing  gelatinous  mucus,  compressing  each  other. 
The  vaginal-portion  is  hard,  tuberous,  from  the  distension  caused  by 
these  projecting  distended  sacs.  Often,  one  or  more  of  these  cysts 
make  their  way  through  the  os  externum,  and,  becoming  more  pe- 
dunculated than  the  rest,  appear  in  the  vagina  as  vesicular  polypi. 

When  these  occur  in  women  past  the  climacteric,  the  touch  and 
appearance  forcibly  suggest  the  suspicion  of  commencing  malignant 
disease.  The  shot-like  hard  projections  around  the  os,  the  red,  or 
bluish-red,  angry-looking  mucous  membrane  in  which  they  are  set, 
make  up  a  condition  hard  to  distinguish.  Usually,  however,  the  vagi- 
nal-portion does  not  become  so  large  as  in  cancer,  and  it  does  not  be- 
come fixed.  It  is  best  treated  by  decided  applications  of  actual  cau- 
tery, or  of  potassa  cum  calce. 

The  ovula  ISTabothi  are  partly  closed  dilated  mucous  sacs  of  the 
mucous  membrane  of  the  cervix,  but  much  more  frequently  they  ap- 
pear as  small  collections  of  nuclei  at  various  depths  in  the  submucous 
tissue  of  the  cervix ;  these  capsules  grow  with  transformation  of  the 
nuclei  to  cells,  and  project  upon  the  surface,  where  they  dehisce,  or  pro- 
lapse as  polypi.  They  contain  a  gelatinous  mucus,  mixed  with  cells 
and  nuclei,  fat-globules,  spindle-shaped  and  many-branched  cells,  and 
colloid  granules. 

When  there  is  free  secretion  of  mucus,  these  polypous,  mucous-mem- 
branous growths,  vesicular  polypi,  and  small  sarcomata  lead  to  contrac- 
tion or  even  closure  of  the  os  uteri,  by  means  of  a  richly  nucleated, 
fibrinous  outgrowth  of  connective  tissue.  This  leads  to  retention  of 
the  gradually  increasing  pus  or  mucus  in  the  uterine  cavity  and  cer- 
vical canal.  The  uterus  may  thus  be  distended  to  the  size  of  a  goose's 
egg,  of  a  fist,  or  even  to  that  of  a  man's  head  ;  its  walls  become  hard, 
sometimes  thinned;  its  raucous  membrane  is  transformed  into  a  smooth 
or  papillary  connective  tissue  growth  ;  its  contents  are  a  colorless  syno- 
vial-like,  or  yellowish,  red-brown,  or  chocolate-colored  glutinous  fatty 
fluid,  showing  cholesterin  or  pus.  This  is  the  so-called  hydrometra. 
When  the  canal  of  the  cervix  gets  distended,  in  like  manner,  the  os 
internum  remaining  narrow,  the  hour-glass  form  of  uterus  is  produced, 
the  uterus  bicameratus.  In  some  rare  cases,  perforation  has  occurred 
through  an  ulcerative  process  allowing  the  contents  to  escape  into  the 
peritoneum. 

This  distension  of  the  uterus  almost  necessarily  leads  to  retrograde 
distension  of  the  Fallopian  tubes,  which  are  even  more  likely  than  the 
uterus  to  undergo  perforation. 

Within  the  period  of  generative  capacity,  chronic  catarrh  may  lead 
to  hypertrophy  of  the  uterus.  During  decrepitude  it  leads  to  relaxa- 
tion and  a  pulpy  state. 

An  exudative  or  croupous  endometritis  is  seen  in  rare  cases  as  a  sec- 
ondary appearance  in  the  course  of  typhoid,  cholera,  exanthemata,  and 
especially  with  a  diphtheritic  inflammation  of  the  vagina. 

Bennet  says  internal  metritis  is  a  rare  form  of  uterine  inflammation  ; 
that  it  has  only  been  considered  common  because  it  has  been  confounded 
with  inflammation  of  the  cavity  of  the  cervix,  a  disease  which  is  very 


UTEEINE    CATARRH.  455 

common.  On  the  other  hand,  it  may  perhaps  not  unfairly  be  said  that 
internal  metritis,  being  out  of  sight,  may  often  escape  recognition. 
Certain  considerations,  however,  incline  me  to  think  that  the  reaction 
against  Bennet's  too  exclusive  limitation  of  inflammation  to  the  cervix, 
has  been  carried  too  far:  1.  In  a  large  number  of  cases,  treatment 
directed  solely  to  the  os  and  cervix  uteri  cures  all  the  disease.  2.  Not 
infrequentlv,  before  the  cervical  disease  is  healed,  pregnancy,  a  function 
which  pertains  to  the  body  of  the  uterus,  and  which  therefore  implies 
a  healthy  condition  of  that  part,  occurs.  3.  The  proportion  of  cases 
in  which  it  is  necessary  to  resort  to  intra-uterine  medication,  although 
certainly  greater  than  Bennet  would  seem  to  acknowledge,  is  limited. 
4.  The  cervix  is  far  more  subject  to  injury  in  parturition. 

Generally  speaking,  endometritis  proper  takes  its"  origin  in  imperfect 
involution  after  labor  or  abortion,  in  obstructed  or  interrupted  men- 
struation, and  in  irritation  from  foreign  bodies  ;  whilst  inflammation  of 
the  cervical  cavity  far  more  frequently  takes  its  rise  in  the  traumatic 
process  of  labor,  in  excessive  sexual  intercourse,  and  in  infection. 
Under  common  origin,  or  by  extension,  there  may  be,  and  frequently 
is,  coexistent  inflammation  of  the  mucous  membrane  of  both  cervix 
and  body. 

It  is  especially,  however,  subjects  of  strumous  or  lymphatic  diathesis 
who  are  prone  to  this  disease.  It  is  remarkable  what  slight  causes 
will  in  such  subjects  produce  it.  And  it  is  in  these  that  the  disease  is 
also  most  rebellious  to  treatment. 

Uterine  and  Vaginal  Catarrh. — The  uterine  and  vaginal  mucous 
membrane  is  liable  to  similar  morbid  influences  to  those  which  attack 
other  mucous  membranes.  For  example,  it  is  liable  to  inflammation 
from  suppression  of  function,  as  from  cold  acting  whilst  the  membrane 
is  in  physiological  hyperemia.  It  is  liable  to  be  affected  by  morbid 
poisons,  as  variola,  scarlatina,  measles,  which  are  carried  to  it  in  the 
blood.  It  is  liable  to  be  affected  by  poisons  or  irritants  directly  applied, 
as  the  poison  of  syphilis  or  gonorrhoea,  or,  as  in  labor,  by  the  poison 
of  scarlatina  carried  by  the  touch. 

Just  as  catarrh  is  produced  in  the  air-tubes  and  intestinal  canal  by 
exposure  to  cold,  damp,  and  irritating  agents,  so  it  is  with  the  mucous 
membranes  of  the  genital  tract.  The  catarrh  so  produced  is  a  subacute 
form  of  inflammation.  The  membrane  becomes  vivid  red,  there  is  a 
sense  of  local  heat,  and  almost  always  there  is  a  raucous  discharge, 
more  or  less  tenacious,  and  varying  in  color  from  cream-white  to  yellow 
and  yellowish-green;  sometimes  it  is  sero-mucous.  If  the  discharge  is 
yellowish-green,  very  abundant,  and  coming  from  a  highly  injected 
surface,  and  the  vagina  and  urethra  be  implicated,  so  that  there  is  pain 
on  micturition,  the  presumption  is  that  the  source  of  the  inflammation 
is  gonorrhoeal  infection.  But  the  greatest  circumspection  is  necessary 
in  giving  an  affirmative  opinion. 

Gonorrhoeal  infection  is  only  one  of  numerous  causes  of  colpitis.  In 
very  many  cases  it  is  impossible  to  assign  the  particular  cause.  There 
is  often  no  distinctive  mark.  Colpitis  is  colpitis.  It  is  often  no  more 
possible — apart  from  history — to  declare  that  a  particular  colpitis  arose 
from  a  specific  cause,  than  it  is  to  declare  the  actual  cause  of  a  case  of 


456  CATARRHAL,    ENDOMETRITIS. 

bronchitis.  The  practitioner  who  is  not  on  his  guard,  is  constantly  in 
danger  of  falh'ng  into  etiological  errors  that  may  entail  the  most  painful 
social  and  domestic  consequences  to  the  patient  and  others,  and  involve 
himself  in  serious  complications.  I  have  known  the  existence  of  leu- 
corrhoeal  discharges  in  girls  give  rise  to  the  suspicion  of  their  having 
been  abused,  when  there  was  the  strongest  reason  to  believe  that  the 
true  source  was  struma,  and  in  one  or  two  cases,  scarlatina.  Here,  as 
in  so  many  difficult  positions  in  medical  practice,  we  must  be  content 
to  limit  our  utterances,  verbal  or  written,  to  the  strictest  conclusions 
from  exact  observations.  The  history  or  extraneous  considerations 
must  be  rigorously  excluded.  To  admit  in  these  delicate  scientific 
questions  the  historical  element  in  forming  a  diagnosis,  is  to  make  our 
opinion  the  reflection  of  the  errors,  the  prejudices,  the  suspicions,  the 
malice  of  others.  Science  has  nothing  to  do  with  all  this.  The  only 
safe  course  is  to  discard  from  our  consideration  everything  but  what 
we  can  subject  to  actual  observation.  The  physician  can  diagnose 
colpitis  when  the  disease  is  before  him.  He  can  only  form  a  conjecture 
as  to  the  cause,  which  cannot  be  before  him. 

The  most  common  form  is  the  catarrhal  endometritis.  This  may  be 
acute  or  chronic. 

The  acute  catarrhal  endometritis  arises  from  the  sudden  action  of  cold, 
especially  if  acting  at  a  menstrual  period,  from  excessive  sexual  inter- 
course, from  gonorrhoeal  infection ;  it  occurs  in  acute  fevers,  especially 
the  exanthemata.  It  is  in  cases  of  the  latter  kind  that  opportunities 
of  studying  the  affection  in  the  dead  body  occur.  The  mucous  mem- 
brane of  the  body  of  the  uterus  presents  red  streaks  or  spots  from  injec- 
tion, or  it  is  uniformly  red,  more  or  less  swollen,  softened,  here  and 
there  bleeding,  and  covered  with  a  red-streaked  mucus,  or  creamy  fluid 
with  pus.  The  submucous  layer  is,  in  severer  cases,  hypersemic,  soft- 
ened, pulpy.  The  mucous  membrane  of  the  cervix  is  at  times  greatly 
injected,  the  contents  of  the  ovula  Nabothi  are  turbid ;  when  burst, 
they  yield  a  thinner  fluid.  The  mucous  membrane  of  the  vaginal- 
portion  is  remarkably  reddened,  its  papillae  are  swollen,  near  the  os 
externum  abraded.  The  parenchyma  of  the  vaginal-portion  is  itself 
swollen.  The  acute  endometritis  often  passes  into  the  chronic.  The 
vagina  also  is  frequently  involved. 

Chronic  Catarrhal  Endometritis. — This  is  frequently  a  continuation  of 
the  acute  form,  and  especially  of  repeated  acute  endometritis  in  cachec- 
tic persons.  It  is  also  frequent  as  the  result  of  morbid  deposits  or 
processes  in  the  mucous  membrane,  as  tuberculization,  or  from  the  irri- 
tation of  tumors  protruding  into  the  uterine  cavities. 

The  mucous  membrane  of  the  body  of  the  uterus  appears  uniformly 
or  in  patches  reddened,  swollen,  spongy,  decidua-like,  or  has  a  granu- 
lar papillary  aspect ;  it  is  covered  vAt\\  a  mucous-purulent  moisture  or 
pus.  Very  often,  chronic  catarrh  consists  essentially  in  blennorrhoea, 
that  is,  in  a  condition  of  profuse* secretion  of  a  more  or  less  hyaline  or 
creamy  opaque  mucus,  from  a  swollen,  partly  pale,  partly  injected, 
dark  brown  or  grayish  pigmented  membrane. 

The  mucous  membrane  of  the  cervix  is  very  often,  but  not  con- 
stantly reddened,  swollen,  especially  on  the  summit  of  its  folds.     It  is 


CHRONIC    CATARRHAL    ENDOMETRITIS.  457 

eomraonly  studded  with  Nabothean  ovules,  and  covered  with  a  clear 
or  yellow-streaked  turbid  mucus. 

The  vaginal-portion  is  often  swollen,  the  mucous  membrane  red- 
dened, its  papillae  swollen  and  injected.  This  condition  and  the  simul- 
taneous presence  of  small  cysts,  give  it  a  villous  granulating  appear- 
ance.    And  not  seldom  there  is  actual  excoriation  or  ulceratiou. 

Although  we  can  only  admit  the  word  "ulceration"  as  describing 
the  loss  of  epithelial  investment  in  the  case  which  forms  the  subject  of 
the  last  chapter  with  some  qualification,  it  seems  impossible  to  discard 
the  term  "inflammation"  as  inapplicable.  It  may  be  described  as  en- 
gorgement, congestion  ;  but  if  this  congestion,  or  whatever  else  it  may 
be  called,  produce  all  the  effects  usually  attending  upon  inflammation, 
the  distinction  becomes  too  subtle  to  be  followed  out.  And  when  it  is 
remembered  that  the  increased  action  going  on,  takes  place  in  a  part 
exposed  to  frequent  fluxions  of  blood,  to  functional  work,  to  accident, 
it  is  hard  to  imagine  how  it  can  long  escape  passing  the  imperceptible 
boundary  which  rigorous  theory,  rather  than  actuality,  places  between 
it  and  inflammation. 

One  fact  may  at  any  time  be  verified,  which  appears  to  lend  support 
to  the  theory  that  inflammation  is  an  essential  factor  in  the  case.  It 
is  the  abundance  of  chlorides  in  the  viscous  secretion  exuding  from 
the  cervix.  The  concentration  of  chlorides  in  inflamed  tissues  is  an 
established  fact.  The  moment  nitrate  of  silver  is  allowed  to  touch  the 
cervical  surface  bared  of  epithelium,  a  dense  opaque  white  layer  is 
produced,  and  any  viscid  secretion  is  instantly  turned  into  a  white  clot 
characteristic  of  chloride  of  silver.  It  has  often  appeared  to  me  that 
the  indication  thus  obtained  of  the  presence  of  an  excess  of  chlorides 
is  very  marked,  and  that  it  may  be  explained  in  the  way  described. 

What  is  the  seat  of  this  inflammation  ?  I  should  say  it  is  exactly 
that  of  the  original  traumatism  sustained  in  labor,  namely,  the  cervix 
uteri,  more  especially  the  lower  part  of  the  vaginal-portion. 

So  far  as  it  concerns  the  case  under  consideration,  I  agree  with 
Henry  Bennet.  It  is  essentially  inflammation  of  the  neck  of  the 
womb,  subacute,  or  chronic.  I  rest  this  conclusion  more  upon  clin- 
ical observation  than  upon  the  anatomical  grounds  so  much  insisted 
upon  by  him.  It  is  true  that  the  structure  of  the  body  of  the  uterus 
differs  from  that  of  the  cervix  in  that  there  is  more  connective  tissue 
in  the  cervix,  and  also  that  the  latter  part  is  in  more  direct  communi- 
cation with  the  source  of  vascular  supply.  But  the  great  reason  why 
the  cervix  is  more  frequently  the  seat  of  inflammation  is,  that  it  is 
more  directly  exposed  to  injmy.  At  the  same  time  I  am  of  opinion 
that  chronic  inflammation  of  the  body,  in  a  less  intense  degree  per- 
haps, commonly  attends  inflammation  of  the  cervix.  Indeed,  it  is 
hardly  possible  for  one  part  to  escape  being  involved  in  a  process  which 
has  seized  upon  the  other.  The  tissue,  muscular  and  mucous,  is  con- 
tinuous ;  the  vascular  supply  is  nearl}'  the  same.  And,  as  a  fact,  we 
observe  by  the  touch  and  sound,  that  in  these  cases  there  is  frequently 
some  enlargement,  and  increased  sensitiveness  of  the  body  of  the 
uterus. 

Still,  there  is  a  striking  feature  in  uterine  pathology  which  lends 


458  ENDOMETRITIS. 

weight  to  Dr.  Bennet's  views.  The  frequent  sharp  limitation  of  tuber- 
cular disease  to  the  body  of  the  uterus,  and  of  cancerous  disease  to  the 
cervix,  seem  to  point  to  some  decided  distinction  in  the  pathological 
proclivities  of  these  regions.  And  their  physiological  destination  is 
equally  distinct.  Both  incontrovertible  facts  j)oint  to  a  difference  of 
structure  which  greatly  favors  the  idea  of  a  difference  in  liability  to 
inflammation.  Another  fact  forcibly  insisted  upon  by  Dr.  Bennet  is, 
that  treatment  applied  to  the  cervix  uteri  is  in  the  majority  of  cases 
sufficient  to  cure  the  patient.  This  appeal  to  the  Hippocratic  maxim, 
"  Curationes  morbum  ostendunt,"  is  difficult  to  resist.  But  is  not  un- 
answerable. Counter-irritants  applied  to  one  part  of  a  diseased  struc- 
ture may,  by  derivation,  or  by  setting  up  healthy  nutrition  in  contigu- 
ous parts,  cure  the  whole  diseased  organ.  And  I  am  in  a  position  to 
affirm  from  observation  in  many  cases,  that  the  cure  is  much  more 
quickly  attained  if  the  treatment  is  extended  to  the  body  of  the  uterus. 

It  appears  to  me  that  attention  has  been  too  strictly  fixed  upon  the 
visible  changes  in  the  cervix  and  os  uteri ;  and  that,  thus  engrossed, 
the  mind  has  been  closed  against  the  less  telling  evidence  of  changes 
in  the  body  of  the  uterus. 

The  body  of  the  uterus  which  formed  the  nidus  of  the  embryo, 
which  underwent  the  most  wonderful  process  of  development,  is  liable 
to  interruption  in  a  process  which  concerns  the  cervix  in  a  very  sec- 
ondary degree.  Involution  especially  affects  the  body  of  the  uterus. 
It  has  to  repair  the  placental  seat,  and  to  restore  the  mucous  lining. 

Disorders  of  involution,  then,  principally  affect  the  body  of  the  uterus. 
Traumatism  principally  affects  the  cervix.  But  in  some  degree  both 
processes  affect  the  whole  uterus. 

Although  the  formative  elements  of  a  new  mucous  lining  exist  in 
the  cavity  of  the  uterus  at  the  time  of  the  separation  of  the  placenta 
and  decidua,  it  can  hardly  be  said  that  a  mucous  membrane,  compar- 
able in  development  to  that  of  the  cervix,  exists.  Whatever  changes, 
then,  of  a  pathological  character  occur  in  the  body  of  the  uterus  after 
labor  must  have  their  chief  seat  in  the  walls  of  the  body,  if  we  except 
the  placental  seat.  That  inflammation  may  spread  from  the  lining 
membrane  to  the  substance  of  the  uterine  wall  can  scarcely  be  doubted; 
but  this  inflammation  does  not  often  extend  deeply.  The  more  usual 
origin  of  metritis  is  in  the  invasion  of  the  vessels  and  lymphatics  by 
foul  matter;  the  coats  of  the  vessels  are  so  delicate  that  irritation 
easily  spreads  from  them  to  the  substance  of  the  uterus  in  which  they 
run.  The  veins  of  the  uterus  can  scarcely  be  said  to  possess  distinct 
coats ;  at  least  it  is  difficult  to  isolate  a  venous  channel  from  the  wall  in 
which  it  runs ;  fibre-cells,  identical  with  those  of  the  uterine  wall,  are 
always  seen  in  abundance  in  the  walls  of  the  veins.  It  is  easy  to  con- 
ceive how  a  tissue,  permeated  by  channels  which  carry  irritating  matter, 
may  become  inflamed  in  its  substance.  This  may  be  actually  seen  in 
the  acute  septicemic  metritis  of  childbed.  Collections  of  pus  are  seen 
in  the  venous  channels,  and  the  surrounding  muscular  structure  is 
softened.  There  is  evidence  enough  to  show,  apart  from  analogical 
argument,  that  a  similar  process  takes  place  in  the  non-pregnant  uterus. 

But,  especially  in  young  women,  in  whom  the  affection  is  the  result 


ENDOMETRITIS.  459 

of  menstrual  suppression  from  cold,  the  inflammation  may  be  strictly 
limited  to  the  body  of  the  uterus.  The  neck  being  less  concerned  in 
the  menstrual  hypersemia,  and  not  subject  to  the  same  physical  disturb- 
ance as  in  married  women,  more  often  escapes. 

In  such  cases,  examination,  limited  to  inspection  through  the  spec- 
ulum, will  fail  to  detect  the  intra-uterine  disease.  But  in  most  cases 
the  cervix  becomes  involved  at  no  distant  period. 

Endometritis  is  a  frequent  consequence  of  obstruction  at  the  os  in- 
ternum or  OS  externum.  Hence,  it  is  not  uncommon  in  women  who 
have  never  been  pregnant,  and  even  in  virgins.  The  contracted  os 
externum,  by  impeding  the  discharge  of  the  menstrual  fluid  and  ordi- 
nary uterine  mucosities,  leads  to  congestion,  irritation,  and  inflammation 
of  the  lining  membrane  of  the  body  as  well  as  of  the  cervix.  Reten- ' 
tion  by  valvular  closure  of  the  os  internum  from  flexion  leads  to  the 
same  consequences.  The  cavity  enlarges  under  the  distending  influ- 
ence of  accumulation ;  the  retained  discharges  undergo  decomposition, 
resulting  in  irritating  matter.  It  is  not  uncommon  for  women  subject 
to  this  aifection,  to  describe  themselves  as  subject  to  "  gathering  and 
bursting  of  an  abscess."  That  is,  there  is  a  stage  of  accumulation  of 
muco-purulent  matter,  during  which  the  pain  of  distension  is  felt, 
merging  in  spasm  or  colic,  the  pain  of  expulsion ;  and  then,  expulsion 
effected,  relief  is  felt.  The  quantity  of  the  fluid  thus  collected  varies, 
and  it  is  difficult  by  direct  observation  to  define  it  correctly.  But  there 
is  little  doubt  that  it  amounts  in  some  cases  to  an  ounce  or  more.  The 
condition  and  the  symptoms  resemble  in  many  points  those  of  dys- 
menorrhoea  from  retention.  Indeed,  dysmenorrhoea  is  often  associated 
with  it,  as  arising  from  similar  mechanical  causes. 

The  discharge  occasionally  becomes  exceedingly  offensive,  has  acrid 
properties  causing  redness  of  the  vaginal  canal  and  vulva ;  and  is,  in 
all  probability,  capable  of  exciting  blennorrhagia  in  the  male. 

Endometritis  may  occur  at  all  ages,  beginning  from  the  outset  of 
menstrual  life  clown  to  old  affe. 

I  have  already  said  that  endometritis  may  be  limited  to  a  particular 
area  of  the  uterine  cavity,  and  that  this  area  is  that  which  was  origin- 
ally the  seat  of  the  placenta.  In  many  cases  the  return  of  this  area  to 
the  normal  state  is  slow  and  imperfect ;  and  for  weeks  and  months  after 
labor  it  may  present  a  rough  surface,  secreting  a  muco-purulent  dis- 
charge, cut  off  by  a  sharp  line  of  demarcation  from  the  smooth,  perhaps 
healthy,  mucous  membrane  of  the  rest  of  the  cavity.  In  the  earlier 
periods,  after  labor,  the  uterine  wall  at  this  part  is  thicker,  and  remains 
more  vascular  than  at  other  parts ;  and  this  comparative  thickness  may 
persist  for  some  considerable  time.  There  is,  in  fact,  imperfect  invo- 
lution, especially  of  this  part  of  the  uterus,  as  the  first  step  of  a  con- 
dition which  merges  into  partial  endometritis  and  metritis. 

Since  the  most  common  seat  of  the  placenta  is  near  the  fundus,  this 
variety  of  disease  might  be  called  "Fundal  Endometritis."  But  this 
name  has  been  used  by  Dr.  Routh  to  describe  a  condition^  which  does 
not  necessarily  depend  upon  pregnancy.     He  says,  that  part  of  the 

1  On  "  Fundal  Endometritis,"  Obstetrical  Trans.,  vol.  xii. 


460  ENDOMETEITIS. 

mucous  membrane  which  lies  between  the  Fallopian  tubes  is  especially 
prone  to  inflammation.  If  he  is  correct  in  his  interpretation  of  the 
cases  he  relates,  he  establishes  the  conclusion  that  there  is  an  endome- 
tritis limited  to  this  particular  area,  which  has  been  confounded  with 
general  endometritis.  Quoting  Dr.  Beck,  he  shows  that  the  fundus  is 
supplied  with  nerves  by  a  branch  coming  from  the  ovary,  that  is,  from 
a  different  source  from  that  which  supplies  the  lower  part  of  the  body 
and  the  neck  of  the  womb.  The  symptoms  are  exactly  those  described 
by  Dr.  Gooch  as  belonging  to  the  "  irritable  uterus."  "  The  abdomen 
is  painful  just  over  the  pubes.  Indeed,  pressure  here  will  often  make 
the  patient  sick."  If  the  sound  be  passed  per  anum  or  per  vesicam, 
and  the  point  be  turned  upon  the  fundus,  pain  will  be  produced.  If 
passed  into  the  uterus,  there  may  be  no  pain  until  the  point  has  passed 
the  OS  internum,  and  has  struck  the  fundus.  "  If  it  be  pressed  at  all 
forcibly  against  the  fundus,  absolute  agony  may  result,  which  may  pro- 
duce vomiting,  an  hysterical  faint  or  fit,  sometimes  a  regular  epileptic 
fit."  The  disease.  Dr.  Routh  says,  is  often  the  result  of  the  use  of  in- 
tra-uterine  passaries,  of  retained  menstruation,  or  the  retention  of  mucoid 
discharges.  Recognizing,  as  my  own  observations  compel  me  to  do, 
the  limited  endometritis  of  the  placental  seat,  to  which  I  confess  to 
have  been  led  more  by  post-mortem  inspections,  at  various  periods  after 
labor,  than  by  clinical  diagnosis,  I  am  not  prepared  to  accept  without 
further  evidence  the  description  of  Dr.  Routh.  I  concur  in  the  opinions 
expressed  by  Dr.  Tilt  and  Dr.  Fordyce  Barker,  at  a  discussion  on  the 
subject  in  the  Obstetrical  Society  (Obstetr.  Trans.,  vol.  xiii),  that  the 
symptoms  relied  upon  are  not  sufficiently  distinctive.  As  Dr.  Barker 
pointed  out,  undoubtedly  the  fundus  is  more  sensitive  than  other  parts 
of  the  uterus.  When  the  sound  touches  it,  pain  is  almost  always  felt; 
and  this  whether  the  organ  be  diseased  or  healthy. 

Dr.  Routh  describes  one  form  of  fundal  endometritis  as  "  convulsive," 
because  he  has  found  some  cases  to  be  attended  with  hysteria  or  other 
variety  of  convulsion. 

I  am  disposed  to  merge  fundal  endometritis  in  general  endometritis. 

The  inflammation  may  be  chiefly  limited  to  the  cervical  cavity.  To 
specify  this  form,  the  objectionable  term  endoGervicitis,  a  barbarous  com- 
pound of  Greek  and  Latin,  is  in  common  use.  It  would  be  better  to 
sacrifice  conciseness,  and  to  speak  of  "  endometritis  cervicalis."  This  is 
a  very  common  affection  ;  and  from  its  seat  being  partly  within  direct 
observation  by  touch  and  sight,  it  has  engrossed  an  undue  share  of 
attention. 

The  Course,  Symptoms,  and  Diagnosis. — The  diagnosis  of  endometritis 
rests  upon  the  subjective  symptoms,  the  history,  and  the  objective 
signs.  The  patient  complains  of  pain  referred  to  the  uterus,  increased 
by  exertion,  attended  often  by  dysuria ;  the  pelvic  pain  radiates  to  the 
back,  and  there  is  more  or  less  constant  lumbo-sacral  heavy  aching 
distress.  Headache  is  also  frequent,  and  various  nervous  symptoms  of 
a  depressing  character  arise  as  the  disease  becomes  chronic. 

The  history  begins  with  pregnancy,  with  arrest  of  menstruation,  with 
intra-uterine  irritation  or  injury,  as  from  wearing  a  pessary,  with  reten- 
tion of  menstrual  discharge,  with  flexion  or  version ;    in  short,  the 


ENDOMETRITIS.  461 

origin  is  in  many  cases  the  same  as  that  of  other  forms  of  uterine  in- 
flammation. The  symptoms  have  probably  at  first  been  acute ;  the 
uterine  pain  was  intense,  setting  in  with  rigor,  perhaps  vomiting,  and 
attended  by  fever.  Passing  into  the  chronic  or  subacute  form,  the 
pain  has  become  less  severe  ;  it  has  been  intermittent,  brought  out  into 
exacerbations  by  overexertion  or  by  menstruation. 

The  objective  signs  are  made  out  by  palpation,  by  the  sound,  and 
by  the  speculum.  Palpation,  vagino-abdominal  or  recto-abdominal, 
will  generally  establish  increased  Aveight  and  bulk  of  the  uterus,  and 
bring  out  pain  or  tenderness  in  the  body  of  the  uterus.  The  sound 
will  commonly  cause  more  pain  than  is  usual  on  entering  the  healthy 
uterus ;  it  will  often  cause  a  little  oozing  of  blood.  Unless  there  be 
flexion,  the  sound  passes  easily,  because  the  orifices  are  almost  certain 
to  be  expanded.  And  when  the  point  is  in  the  cavity,  the  dilatation 
of  this  part  is  made  manifest  by  the  freedom  with  which  the  sound  can 
be  turned  round.  The  uterus  has  lost  its  flattened  condition,  havino; 
become  more  pear-shaped. 

Diagnostic  purj)ose  being  fulfilled,  it  is  henceforth  desirable  to  use 
the  sound  as  little  as  possible.  It  is  often  a  source  of  irritation.  The 
speculum  will  in  most  cases  show  some  amount  of  congestion  of  the 
vaginal-portion,  perhaps  abrasion  or  other  lesion ;  but  tliis  is  an  acci- 
dental not  a  necessary  complication. 

Gosselin  and  Aran,  describing  the  frequency  of  so-called  ulcerations 
seen  around  the  margin  of  the  os  uteri  in  chronic  endometritis,  affirm 
that  they  have  little  significance,  and  are  generally  the  result  of  the 
maceration  of  the  epithelium  in  the  mucous  secretions.  As  soon  as  the 
discharge  lessens  the  ulceration  heals  rapidly.  I  must,  however,  re- 
mark that  in  most  cases  which  follow  labor,  the  loss  of  epithelium  is 
due  to  the  necrotic  action  I  have  described. 

Very  acute  pain,  evoked  by  touching  the  fundus  externally,  is  either 
an  indication  of  extreme  hypersesthesia  in  the  subject,  or  of  inflamma- 
tion of  the  substance  of  the  uterus. 

When  chronic  or  subacute  catarrh  arises  primarily,  that  is,  without 
acute  beginning,  leucorrhoea  is  often  the  first  symptom  which  attracts 
attention.  Then  pain  on  excretion  follows.  Dysmenorrhoea  becomes 
more  pronounced.  This  last  symptom  is  the  more  important  in  women 
who  previously  had  not  suffered  from  dysmenorrhoea.  There  are 
many  women  in  whom  dysmenorrhoea  may  be  called  secondary,  that 
is,  it  is  acquired  as  a  consequence  of  metritis  or  non-involution  after 
labor. 

Menorrhagia  is  a  frequent  attendant.  The  tumid,  engorged,  vascular 
mucous  membrane  easily  allows  blood  to  exude.  The  catamenia  return 
in  advance  of  the  proper  period,  that  is,  every  three  weeks  or  fortnight, 
and  last  for  a  week  or  more,  sometimes  profusely.  The  blood-flow  is 
commonly  succeeded  by  a  muco-puriform  discharge ;  and  not  seldom, 
slight  causes  will  determine  a  flow  of  blood  in  the  intermenstrual 
periods.  A  common  remark  is  that  the  flow  returns  a  day  or  two  after 
having  apparently  ceased,  so  that  the  subject  hardly  knows  when  the 
period  is  fairly  at  an  end.  Sometimes  clots  of  dark  blood  "  like 
leeches  "  are  voided.     In  one  case  of  intense  endometritis  the  woman 


462  ENDOMETRITIS. 

passed  every  morning  a  cylindrical  mass  about  three  inches  long,  slimy 
and  streaked  with  blood. 

Dysmenorrhoea  more  especially  attends  the  catarrhal  inflammation 
of  the  body  of  the  uterus,  probably  because  this  condition  is  apt  to 
involve  some  degree  of  inflammation  of  the  uterine  wall  itself.  The 
form  in  which  dysmenorrhcBa  appears  is  uterine,  that  is,  pain  is  felt 
shortly  before  and  at  the  time  of  the  uterine  flux ;  it  is  referred  to  the 
uterus  or  middle  of  the  pelvis,  and  radiates  to  the  loins  and  sacrum. 

In  the  milder  forms  of  catarrh,  the  discharge  is  chiefly  mucus  entan- 
gling epithelial  cells ;  it  may  be  clear  or  opaque.  The  hypertrophied 
uterine  glands  at  times  pour  out  a  profuse,  even  exhausting,  secretion. 
In  severer  forms  it  is  often  tinged  with  blood.  This,  Bennet  says,  is 
as  characteristic  as  is  the  rusty  sputa  of  pneumonia.  It  is  due  to  the 
intense  congestion,  the  blood  easily  permeating  the  thin  epithelial 
covering. 

The  neighboring  organs  are  commonly  somewhat  disturbed.  In  the 
acute  forms,  even  dysenteric  symptoms  may  be  produced.  In  the 
chronic  forms  diarrhoea  is  not  uncommon,  alternating  perhaps  with 
constipation.  Diarrhoea  in  the  acute  form,  however,  is  not  alone  the 
consequence  of  proximate  irritation  ;  it  is  more  likely  to  be  due  to 
septicEemia.  Both  in  the  acute  and  chronic  forms  some  bladder-distress 
is  a  frequent  attendant.  Dysuria  and  frequent  micturition,  and  some- 
times cystitis,  are  observed. 

Disorder  of  nutrition  and  of  the  nervous  system  are  sure  to  follow 
sooner  or  later  upon  chronic  uterine  catarrh.  The  abnormal  derivation 
of  vascular  and  nervous  action  leaves  the  digestive  organs  imperfectly 
supplied ;  and  the  constant  wear  and  tear  of  pain  exhausts  the  nervous 
centres.  Hence  the  appetite  is  impaired,  capricious,  difficult  to  stimu- 
late. Despondency,  fretfulness,  sometimes  hysterical  symptoms  harass 
the  patient.  Nausea,  vomiting,  gastralgia,  distension  of  the  stomach 
follow.  The  urine  becomes  turbid,  loaded  with  uric  acid  or  phosphates, 
and  sometimes  with  mucus.  This  is  especially  the  case  in  women 
towards  middle  age,  with  a  tendency  to  obesity  and  sluggish  liver. 

In  other  cases,  the  discharges  and  the  impaired  nutrition  entail  ema- 
ciation. The  face  puts  on  a  dull,  languid,  worn  expression ;  the  fades 
uterina  becomes  formed.  The  features  fall ;  dark  circles  surround  the 
eyes. 

Acute  endometritis  may  end  in  spontaneous  recovery.  Perhaps  rest 
and  careful  regimen  for  a  few  weeks  may  suffice  for  cure.  But  of  the 
accomplishment  of  this  we  cannot  be  certain,  until  one  or  two  menstrual 
periods  have  passed  by  without  rekindling  the  symptoms.  The  signs 
of  cure  are :  the  cessation  of  febrile  movement  and  of  local  pain  ;  the 
moderation  of  discharge,  the  closure  of  the  os  externum  uteri,  and  the 
return  of  the  mucous  membrane  of  the  cervix  to  its  natural  pink  color. 
Chronic  endometritis,  on  the  other  hand,  is  a  most  obstinate  disorder. 
It  shows  little  disposition  to  spontaneous  cure.  Some  observers  in- 
deed doubt  whether  it  can  even  be  cured  by  art.  But  this  doubt  I 
do  not  share.  A  well-directed  local  treatment  will  almost  certainly 
be  followed  by  success,  unless  there  be  diathetic  or  other  morbid  com- 
plications. 


ENDOMETRITIS.  463 

Scanzoni  throws  almost  equal  doubt  upon  the  curability  of  chronic 
endometritis,  that  he  does  upon  chronic  metritis.  Chronic  catarrh,  he 
urges,  is  the  almost  never-failing  companion  of  chronic  parenchymatous 
metritis,  and  how  shall  it  be  healed  whilst  the  disorders  of  the  circula- 
tion in  the  walls  of  the  organ  persist  ?  How  shall  the  hypersemia, 
swelling,  and  hypersecretion  of  the  mucous  membrane  disappear  whilst 
the  causative  disorders  in  the  wall  of  the  uterus  persist  ?  I  have  already 
discussed  the  possibility  of  cure  of  parenchymatous  metritis.  If  this 
possibility  be  admitted,  then  the  possibility  of  curing  endometritis 
follows  as  a  corollary. 

I  cannot  help  attributing  this  eminent  physician's  unfavorable  opinion, 
in  some  measure,  to  his  imperfect  estimate  of  the  etiological  importance 
of  constriction  of  the  os  externum  uteri,  and  of  flexion.  Treatment 
which  fails  to  take  cognizance  of  these  conditions  must  necessarily  be 
imperfect,  and  wuU  therefore  often  fail. 

The  indication  to  begin  by  removing  any  complication,  such  as 
flexion,  inflammation  of  the  vaginal-portion  or  cervix,  or  atresia,  is 
obvious.  Indeed,  the  principal  remedies,  those  to  be  applied  to  the 
interior  of  the  uterus,  cannot  be  brought  into  use  until  the  cervical 
canal  is  made  permeable  for  at  least  a  No.  8  or  No.  9  catheter. 

Inflammation  or  engorgement  of  the  cervix  must  be  subdued  by 
the  methods  already  described.  And  when  this  is  done,  it  will 
sometimes  be  found  that  the  signs  of  endometritis  have  disappeared. 
Whether  it  be  by  derivation  or  by  other  agency,  curing  inflammation 
of  the  cervix  will  sometimes  cure  inflammation  of  the  body  too.  But, 
although  this  is  an  essential  part  of  the  treatment,  it  ought  not  to  be 
trusted  to  alone.  For,  if  it  occasionally  is  sufficient  to  cure,  yet  the 
process  being  indirect  is  slow  and  tedious.  It  is  remarkable  and 
gratifving  to  observe,  in  some  cases,  how  quickly  a  long-standing  case 
of  endometritis  is  cured  by  direct  treatment. 

The  Treatment. — In  the  acute  stage,  which  is  most  likely  complicated 
with  metritis  proper,  the  application  of  twenty  leeches  to  the  hypogas- 
trium,  fomentations,  sedatives,  salines,  will  be  necessary.  In  the  chronic 
stage,  the  cure  will  depend  greatly  upon  the  judicious  use  of  intra- 
uterine remedies.  Just  as  in  the  case  of  chronic  inflammation  and 
hypertrophy  of  the  fauces  with  its  glands,  topical  applications  offer  the 
most  effective  means  of  bringing  about  a  healthy  condition  of  the 
altered  tissues.  The  solid  nitrate  of  silver,  wdiich  acts  so  well  else- 
where, is  of  signal  service  in  this  case.  The  sulphate  of  zinc  I  have 
found  almost  equally  beneficial ;  and  it  has  the  advantage  of  being 
safer.  But  tincture  of  iodine,  carbolic  acid,  chromic  acid,  chlorate  of 
potash,  perchloride  and  persulphate  of  iron,  nitric  acid,  acetic  acid, 
have  all  been  extolled.  These  remedies  are  best  applied  either  solid 
or  in  the  form  of  ointment,  or  as  liquid  carried  on  swabs.  The  prac- 
tice of  injecting  liquids  into  the  uterine  cavity  offers  no  marked  advan- 
tages over  the  methods  described,  and  the  attendant  objections  are  so 
serious  that  it  is  desirable  to  discuss  the  subject  of  intra-uterine  medi- 
cation with  special  care. 


464  ENDOMETRITIS. 


The  various  Modes  of  applying  Remedies  to  the  Internal  Surface  of  the 

Uterus. 

The  treatment  of  morbid  conditions  of  the  body  of  the  uterus  by 
intra-uterine  injections  is  a  subject  that  calls  for  earnest  discussion  on 
account  of  its  utility  and  its  dangers.  If  we  treat  morbid  conditions 
of  the  eye,  mouth,  throat,  larynx,  bladder,  rectum,  and  vagina  by 
injections  with  such  manifest  advantage  that  we  have  come  to  look 
upon  this  method  as  in  many  cases  indispensable,  it  seems  reasonable 
to  expect  equal  advantage  from  its  action  on  the  mucous  membrane  of 
the  cavity  of  the  uterus.  Experience  amply  justifies  this  expectation. 
Topical  applications  to  the  diseased  mucous  membrane  are  in  many 
cases  essential  to  cure.  But  in  the  form  of  injected  fluids  they  are  not 
free  from  danger.  Almost  every  author  who  has  w^ritten  upon  the 
subject,  refers  to  cases  of  accidents,  ranging  from  severe  pain  to  shock, 
collapse,  metritis,  perimetritis,  and  death.  It  is  desirable  to  refer  to 
some  of  these  cases  which  best  illustrate  the  conditions  of  danger. 

Henry  Bennet  relates  a  case  which  occurred  under  Jobert.  A  girl, 
aged  twenty-four,  had  a  large  fibroid  of  the  uterus.  Jobert  made  an 
astringent  injection  into  the  cavity  of  the  neck.  Almost  immediately 
there  arose  shiverings,  agonizing  pains  in  the  abdomen,  then  fever,  then 
death  in  a  few  days  from  metro-peritonitis.  Bennet  performed  the 
autopsy.     He  found  nothing  besides  the  marks  of  peritonitis. 

In  my  work  on  '' Obstetric  Operations"  (2d  ed.,  1871),  I  have 
related  a  case  which  occurred  in  the  London  Hospital  after  I  had  left 
that  institution.  The  history  was  supplied  to  me  by  Mr.  Hermann, 
resident-accoucheur  at  the  time,  and  the  account  of  the  autopsy  by  Dr. 
Sutton.  A  woman,  aged  forty-eight,  had  had  six  children  and  five 
abortions.  For  eighteen  months  she  had  suffered  from  menorrhagia. 
On  admission  there  was  decided  retroflection  of  the  uterus.  An  in- 
jection of  perchloride  of  iron,  in  the  proportion  of  one  part  of  the  satu- 
rated solution  to  six  of  water  was  used.  About  half  a  pint  of  this  was 
injected  through  a  double-channel  catheter  attached  to  a  Higginson's 
syringe,  the  patient  lying  on  her  left  side.  The  fluid  appeared  to  flow 
out  as  fast  as  it  entered.  The  catheter  was  kept  half  rotated,  so  as  to 
hold  the  uterus  in  its  proper  axis  during  the  injection.  The  os  uteri 
had  been  well  dilated.  Immediately  after  the  operation  the  patient 
complained  of  intense  pain  in  the  abdomen.  In  the  evening  the  pain 
was  worse,  and  she  had  vomited.  The  pulse  and  temperature  rose, 
and  she  died  in  collapse  fifty-eight  hours  after  the  injection.  In  the 
peritoneal  cavity  was  found  a  quantity  of  blackish-green  opaque  puri- 
fbrm  fluid.  Much  of  the  peritoneum  covering  the  intestines  around 
the  uterus  w^as  of  a  black  color.  There  was  a  quantity  of  pus  in  the 
pelvis.  The  left  Fallopian  tube  was  enlarged,  and  the  vessels  on  its 
peritoneal  surface  highly  injected.  The  outer  half  of  the  tube  was 
much  dilated,  and  filled  with  dirty,  pus-like  fluid.  There  was  marked 
retroflexion  of  the  uterus.  Dr.  Sutton's  opinion  was  that  the  fatal 
peritonitis  was  caused  by  the  iron  solution  escaping  through  the  Fallo- 
pian tube  into  the  peritoneal  cavity. 


INTRA-UTEEINE    MEDICATION.  465 

Dr.  v.  Haselberg  relates  an  instructive  case.^  A  jpueJla  publica, 
having  had  an  abortion  six  months  before,  came  under  treatment  with 
anteflexion  of  the  uterus  to  such  an  extent  as  to  render  the  pas- 
sage of  the  sound  difficult.  She  suffered  from  profuse  menorrhagia, 
and  it  was  determined  to  try  injection  of  perchloride  of  iron.  It  was 
only  after  repeated  trials  that  the  syringe  was  made  to  pass  beyond 
the  seat  of  flexion  into  the  cavity  of  the  uterus.  The  patient  suffered 
no  pain  at  the  time,  but  at  night  had  a  severe  rigor.  On  the  fifth 
night  rigor  was  accompanied  by  severe  vomiting,  and  abdominal  pains 
immediately  ensued.  On  the  following  night  this  was  repeated,  where- 
upon she  fainted  and  died.  The  intestines  were  found  united  by  recent 
exudation.  The  lower  parts  of  the  pelvis  were  filled  with  stinking 
pus  ;  the  source  of  this  was  discovered  in  a  cyst  in  the  right  ovary, 
which,  through  a  small  opening,  gave  issue  to  like  matter.  The  right 
tube  was  permeable  throughout  its  Mdiole  length  by  a  large  sound. 
The  mucous  membrane  of  the  uterus  was  stained,  as  if  with  ink,  and 
the  same  appearance  extended  along  the  right  tube.  The  black  patches 
showed  iron  by  chemical  tests.  One  fact,  at  least,  is  clear  from  this 
case, — that  perchloride  of  iron,  like  other  fluids,  may  run  along  the 
Fallopian  tubes.  But  it  is  not  so  obvious  that  the  fatal  result  was 
due  to  this  accident.  No  immediate  symptoms  followed  the  injection. 
The  signs  of  intra-abdominal  injury  seem  due  to  the  perforation  of  the 
ovarian  cyst  under  the  pressure  of  vomiting. 

Hourmann,  of  Lourcine,  relates  the  following :  A  girl,  aged  nine- 
teen, had  profuse  leucorrhoea.  He  injected  a  decoction  of  nut  by  a 
clysopompe  into  the  uterus.  At  the  first  stroke  she  cried  out  and  put 
her  hand  to  the  left  iliac  region.  Severe  shivering  set  in,  and  lasted 
several  hours  ;  then  febrile  reaction  followed.  The  pain  spread  to  the 
abdomen,  indicating  metro-peritonitis.  Hemorrhage  appeared  in  two 
days,  and  she  was  relieved. 

It  deserves  notice  that  the  intense  pain  called  forth  by  applying 
various  substances  into  the  cavity  of  the  uterus  is  most  frequently  of 
the  nature  of  colic  ;  it  does  not  generally  indicate  metritis. 

Metritis  may,  however,  be  caused  if  the  substances  used  are  caustic, 
as  distinguished  from  styptic  or  astringent.  This  difference  of  course 
depends  upon  the  degree  of  concentration  of  the  agents  employed.  It 
is  a  point  which  has  been  strangely  neglected  by  some  practitioners, 
who  having  used  caustic  solutions  of  perchloride  of  iron  to  arrest  hem- 
orrhage, have  caused  sloughing  of  the  uterus,  and  have  straightway 
condemned  the  agent,  instead  of  their  own  want  of  discretion  in  the  use 
of  it. 

The  danger  of  fluids  running  along  the  Fallopian  tubes  seems  to 
depend  upon  undue  patency  of  these  canals.  This  undue  patency  in 
its  turn  is  owing  in  many  cases,  at  least,  to  obstruction  at  some  lower 
part  of  the  utero-vaginal  canal.  Thus  in  V.  Haselberg's  case,  and 
in  the  one  at  the  London  Hospital,  there  were  decided  flexion  of  the 
uterus  and  dilatation  of  the  tubes. 

It  is  not  enough  to  know  that  patients  occasionally  die  after  injec- 

1  Monatsschrift  fiir  Geburtskunde,  1869. 
30 


466  ENDOMETRITIS. 

tions  are  thrown  into  the  uterine  cavity — we  want  to  know  why  they 
die.  Knowing  this,  we  may  learn  how  to  avoid  the  causes  of  danger, 
without  abandoning  the  use  of  a  mode  of  treatment  which  renders  in 
a  great  number  of  cases  incontestable  service. 

Many  experiments  have  been  made  on  the  dead  body  to  ascertain 
the  behavior  of  injections.  Hennig,  Klemm,  Guyon,  Fontaine  [on 
'puerperce),  Alph.  Gu6rin,  Guichard,  Scanzoni,  and  others  have  done 
this.  The  experiments  generally  show  that  there  is  extreme  difficulty 
in  making  fluids  run  along  the  tubes,  especially  if  the  injecting 
syringe  does  not  completely  fill  the  os  uteri  internum.  I  will  not 
relate  or  analyze  these  experiments,  because  they  appear  to  me  to  be  of 
little  practical  value.  The  conditions  of  the  dead  and  of  the  living 
tissues  are  essentially  different.  For  example,  in  the  dead  body  there 
is  no  muscular  contractility,  no  irritability  under  stimulus,  no  response 
of  the  nervous  centres  to  peripheral  injury.  Yet  these  are  conditions 
which  come  into  play  when  injections  are  thrown  into  the  living  uterus. 
It  may,  indeed,  seem  at  first  sight  that  these  experiments  would  at  any 
rate  illustrate  the  problem  of  the  permeability  of  the  Fallopian  tubes. 
But,  even  here,  their  value  is  small.  They  may  prove  that  great  force 
is  necessary  to  drive  fluid  along  these  canals ;  and  that,  unless  the 
cavity  of  the  uterus  be  closed  below,  as  at  the  cervix,  fluids  will  rather 
regurgitate  than  run  onwards.  But  it  is  certain  that  in  some  of  the 
cases  where  fluid  injected  into  the  living  uterus  ran  along  the  tubes, 
the  accident  could  not  be  accounted  for  by  the  very  small  amount  of 
injecting-force  employed.  Another  power,  therefore,  must  have  been 
in  action,  and  this  could  be  no  other  than  that  exerted  by  the  uterus 
itself  contracting  spasmodically  upon  the  irritating  fluid  thrown  into 
it.  This  force,  the  lower  or  cervical  orifice  of  the  uterus  being  closed, 
w^ould  pump  the  fluid  onwards  into  the  tubes. 

Dr.  J.  Whitehead,  in  a  valuable  practical  paper  (Brit.  Med.  Journal, 
1873),  suggests  that  fluids  may  be  carried  onward  into  the  peritoneum 
by  capillary  or  ciliary  action.  He  prefers  the  use  of  solid  or  unctu- 
ous substances. 

Again,  it  is  not  necessary  for  the  production  of  alarming  or  even 
fatal  accidents,  that  the  fluid  should  run  along  the  tubes.  The  fluid 
injected  into  the  cavity  of  the  uterus  may  cause  metritis,  and  the  inflam- 
mation may  spread  to  the  adnexa  and  to  the  peritoneum.  Or  severe 
pain,  shock  and  collapse  may  be  the  immediate  and  simple  result  of 
the  irritation  produced  on  the  uterine  superficies  by  the  contact  and 
retention  of  the  fluid.  The  agony  attending  some  cases  of  dysraenor- 
rhcea  is  simply  due  to  the  irritation  set  up  by  retained  blood  causing 
uterine  contractions  or  colics.  The  pain,  the  prostration,  the  other 
nervous  phenomena  attending  dysmenorrhcea  are  sometimes  as  severe 
as  those  attending  intra-uterine  injections. 

In  some  unfortunate  cases,  as  in  one  related  by  Tessier,  the  fluid 
injected  has  been,  not  simply  of  styptic  and  congulating  power,  but 
actually  caustic.  It  ought  to  be  needless  to  point  out  so  fundamental 
an  error.  But  it  has  been  committed  more  than  once ;  and  the  fault  ol 
the  operator  has  been  assigned  to  the  method. 

It  is  not  even  necessary  that  fluids  should  be  injected  into  the  uterus 


INTRA-UTERINE    MEDICATION.  467 

at  all.  I  have  seen  pain  and  collapse  so  severe  as  to  cause  the  utmost 
anxiety  for  the  result,  follow  an  ordinary  injection  of  weak  sulphate  of 
zinc  into  the  vagina.  This  occurred  in  the  case  of  a  lady,  whose 
maid  was  administering,  as  she  had  often  done  before,  a  zinc  solution, 
by  means  of  a  Higginson's  syringe.  The  cervix  in  this  case  was  pat- 
ulous, but  it  is  certain  that  the  pipe  of  the  syringe  was  not  inserted  into 
it.     She  recovered  in  some  hours,  no  inflammation  supervening. 

It  will  further  be  remembered  that  the  mere  touch  of  a  sound  or 
bougie  against  the  fundus  uteri  will  in  some  cases  produce  severe  pain, 
and  even  prostration. 

Again,  symptoms  resembling  in  character  and  severity  those  caused 
by  injected  fluids,  are  occasionally  observed  when  solid  or  unctuous 
substances  are  used,  which  cannot  from  their  nature  flow  along  the 
tubes,  which  must,  in  short,  act  in  loco. 

Thus,  Aran  says  he  has  known  three  cases  of  fatal  peritonitis  from 
actual  cauterization  of  the  os  uteri,  and  one  case  of  fatal  ovaritis  from 
the  application  of  Vienna  paste. 

I  have  known  the  most  severe  pain  and  prostration  followed  by 
hemorrhage  and  metritis,  caused  by  the  application  of  solid  nitrate  of 
silver  to  the  interior  of  the  uterus ;  and  I  have  seen  fatal  peritonitis 
follow  the  simple  application  of  nitrate  of  silver  to  the  cervix  uteri. 

The  severity  of  the  accidents  is  not  explained  by  the  nature  of  the 
fluids  injected.  Alarming  symptoms  have  followed  the  use  of  compar- 
atively weak  solutions.  It  has  been  supposed  in  these  and  other  cases 
that  the  untoward  phenomena  were  due  to  the  forcible  propulsion  of 
air  along  with  the  fluid.  In  some  cases  this  hypothesis  may  be  well 
founded.  But  I  think  its  importance  has  been  exaggerated.  It  is  even 
doubtful  whether  a  quantity  of  air  at  all  calculated  to  produce  serious 
distress  can  be  driven  into  the  vessels  or  tissues  of  the  unimpregnated 
uterus  ;  and  the  small  quantity  that  might  possibly  run  along  the  Fal- 
lopian tubes  into  the  peritoneal  cavity  could  hardly  do  much  harm. 

One  all-important  caution  is  to  be  religiously  observed,  namely, 
never  to  use  any  topical  application  to  the  uterus,  or  to  perform  any  sur- 
gical operation  upon  the  uterus,  ivhen  a  menstrual  period  is  impending. 

It  is  at  this  time  when  the  menstrual  flux  is  imminent,  when  the 
nervous  system  is  at  its  acme  of  excitability,  that  even  slight  causes 
are  sufficient  to  light  up  acute  inflammation.  At  this  time,  it  may  be 
said,  the  uterus  resents  all  interference. 

Dr.  Cohnstein  gives^  a  careful  historical  survey  of  the  practice  and 
opinions  of  those  who  have  related  their  experience  upon  this  subject. 
The  general  conclusion  arrived  at  is  that  injection  of  very  powerful 
caustics  is  likely  to  cause  inflammation  of  the  uterus  and  peritoneum, 
or  severe  prostration  and  uterine  colics ;  and  that  these  dangers  are  less 
urgent  if  care  be  taken  first  to  dilate  the  cervix. 

Dr.  Lente^  discusses  this  question,  passing  under  review  the  various 
topical  methods  of  treating  disease  of  the  cavity  of  the  uterus.  Iodine 
in  solution  he  has  known  cause  intense  pain  and  alarming  collapse, 
which,  however,  passed  away,  no  further  bad  effect  ensuing. 


1  Beitra2:e  zu  Chronischen  Metritis,  1868. 
"^  New  York  Journal  of  Medicine,  1870. 


468  ENDOMETRITIS. 

The  leading  gynaecologists  of  New  York  have  also  discussed  this 
question.  Instances  of  serious  accidents  were  adduced.  The  general 
opinion  seemed  adverse  to  the  use  of  intra-uterine  injections,  whilst 
Dr.  Thomas  was  especially  emphatic  in  his  condemnation. 

To  avoid  the  dangers  of  intra-uterine  injections,  several  j)i'ecepts 
have  been  enjoined.  The  great  object  aimed  at  is  to  avoid  or  lessen 
the  risk  of  the  fluid  running  along  the  tubes.  This  it  is  sought  to 
attain — 

1st.  By  securing  free  dilatation  of  the  cervix  uteri  before  injecting, 
so  that  the  fluid  may  readily  run  back  into  the  vagina.  For  this  pur- 
pose the  preliminary  use  of  laminaria-tents  is  advised. 

2d.  By  using  only  graduated  quantities  of  fluids,  and  injecting  very 
gently  and  slowly. 

3d.  By  using  a  double  canula,  so  as  to  secure  a  return-current.  To 
effect  this  the  more  surely,  the  openings  of  the  canulse  at  the  uterine 
end  are  made  at  different  levels. 

I  have  not  much  faith  in  the  double  canula.  The  end  which  should 
serve  for  the  return-current  is  liable  to  be  choked.  The  preliminary 
free  dilatation  of  the  cervix  and  the  use  of  gentleness  in  propel- 
ling the  fluid  should  never  be  omitted.  But  I  do  not  believe  that 
the  observance  of  these  precautions  is  an  absolute  guarantee  against  ac- 
cidents. It  is  probable  that  the  mere  forcible  impact  of  any  fluid 
striking  upon  the  inner  surface  of  the  uterus,  especially  upon  the  fun- 
dus, may  cause  severe  pain  and  prostration.  Since  nothing  is  gained 
by  forcible  injection,  this  consideration  affords  additional  reason  for  in- 
jecting with  all  possible  gentleness.  Hence,  it  is  well  to  use  injecting- 
pipes  having  lateral  openings  of  very  fine  calibre,  so  as  to  "pulverize" 
the  liquid.  I  strongly  advise  not  to  use  injections  at  all  in  cases  of 
marked  flexion  of  the  uterus.  Even  if  we  dilate  the  cervix  first  by 
tents,  and  maintain  the  uterus  erect  during  the  injection,  we  cannot 
always  be  sure  that  the  flexion  will  not  be  reproduced,  so  as  to  prevent 
the  issue  of  the  fluid  ;  and  it  must  not  be  forgotten  that  it  is  especially 
in  these  cases  that  the  uterine  cavity  is  likely  to  be  enlarged,  and  the 
Fallopian  tubes  dilated. 

The  general  conclusion  at  which  I  have  arrived  is  to  restrict  the  use 
of  intra-uterine  injections  within  the  narrowest  limits.  I  rarely  em- 
ploy them  now,  except  in  cases  of  urgent  danger  from  metrorrhagia. 

We  may  obtain  almost  all  the  advantages  that  injections  are  capable 
of  giving  by  other  means.  For  example,  the  same  agents  which  are 
so  useful  in  the  form  of  solutions  for  injection,  may  be  applied  either 
by  swabbing,  or  solid,  or  in  the  form  of  ointment.  Thus,  wliere  the 
use  of  chromic  or  nitric  acid,  perchloride  of  iron,  iodine,  or  bromine,  is 
indicated,  these  agents  can  be  applied  soaked  on  a  sponge  or  piece  of 
cotton,  or  on  a  glass  or  hair-pencil,  having  previously  well  dilated  the 
cervix.  Nitrate  of  silver  is  far  better  applied  in  the  solid  form.  Even 
then  it  is  liable  to  cause  severe  colic.  The  risk  of  this  may  be  lessened  by 
reducing  the  t^austic  by  fusing  it  with  equal  parts  of  nitrate  of  potash. 

The  ordinary  way  of  using  the  solid  nitrate  of  silver,  that  is,  by 
holding  a  piece  of  the  stick  in  a  forceps  or  porte-crayon,  is  objection- 
able.    The  piece  may  fall  out  or  break,  and  a  fragment  left  behind  in 


INTEA-T7TERIXE    MEDICATION.  469 

the  cervix  or  body  of  the  uterus  may  give  rise  to  intense  agony,  and 
even  metritis.  To  avoid  this  accident  I  have  for  many  years  used  the 
contrivance  figured  on  p.  129  (Fig.  42). 

This  is  far  the  best  way  of  applying  nitrate  of  silver  to  the  os  and 
cervix  uteri,  and  it  is  the  only  safe  way  of  applying  it  to  the  interior 
of  the  uterine  cavity.  The  armed  end  of  a  probe  may  be  passed  into 
the  uterus  without  the  speculum,  although  the  aid  of  this  instrument 
is  sometimes  convenient.  For  example,  unless  the  armed  probe  is  pro- 
tected by  a  canula,  the  caustic  will  first  touch  the  vulva  and  vagina 
in  its  passage,  which  is  apt  to  have  unpleasant  effects,  and  the  guiding 
finger  of  the  operator  will  be  stained. 

One  of  the  most  widely  useful  topical  applications  to  the  mucous 
membrane  of  the  cervix  and  body  of  the  uterus  is  sulphate  of  zinc. 
The  value  of  this  agent,  when  applied  to  the  relaxed  or  morbid  mucous 
membrane  of  the  vagina  in  the  form  of  injections,  is  familiarly  known. 
How  to  apply  it  to  the  uterine  mucous  membrane  is  therefore  a  matter 
of  great  interest.  A  solid  stick  of  two  or  three  grains  can  be  carried 
quite  into  the  uterus  without  having  touched  the  vagina  by  the  way, 
by  means  of  my  canula  (Fig.  43,  p.  129),  now  generally  sold  by  in- 
strument makers. 

It  is  a  great  advantage  of  this  contrivance,  that  the  use  of  the  spec- 
ulum is  Cjuite  unnecessary  after  it  has  aided  in  establishing  the  diag- 
nosis which  supplies  the  indication  in  treatment.  When  the  instrument 
has  gone  the  proper  depth,  the  piston  pushes  out  the  stick,  and  the 
instrument  is  withdrawn,  leaving  the  stick  to  dissolve.  This  it  soon 
begins  to  do,  and  by  its  speedy  effect  in  constringing  the  mucous  mem- 
brane, it  keeps  itself  ?n  situ  until  it  is  completely  dissolved. 

iXitrate  of  silver  reduced  by  admixture  with  nitrate  of  potash  may 
be  used  in  the  same  way.  So  may  persulphate  of  iron,  but  this  should 
be  considerably  reduced.  When  used  nearly  pure,  I  have  known  it 
cause  severe  colic  and  bleeding. 

A  most  precious  way  of  applying  astringents,  caustics,  solvents,  or 
alteratives,  to  the  interior  of  the  uterus,  is  in  the  form  of  ointment  or 
pasma.  In  this  way  almost  any  substance  may  be  applied.  Where 
grease  is  objectionable  as  a  vehicle,  a  pasma  of  suitable  consistence  may 
be  made  by  glycerin  or  other  substances.  In  this  form  we  may  use  rem- 
edies which  cannot  easily  be  applied  in  any  other  way.  For  example,  we 
can  hardly  use  bromine,  or  iodine,  or  mercury,  in  a  solid  shape;  and  to 
use  them  in  the  liquid  form  is  open  to  the  objections  already  discussed. 
Almost  anything  can  be  made  into  an  ointment  or  pasma;  and  we  thus 
get  a  complete  practical  command  over  a  large  range  of  useful  agents. 

To  introduce  ointment  into  the  cavity  of  the  uterus,  the  instrument 
figured  at  p.  129,  Fig.  44,  is  both  convenient  and  effective.  It  is  used 
without  aid  of  the  speculum.  It  is  charged  by  dipping  the  end  into 
the  ointment.  This  carries  a  sufficient  quantity  into  the  uterus,  when, 
by  pushing  home  the  piston,  the  ointment  is  deposited  there. 

If  it  be  desired  to  apply  a  powerful  licjuid  caustic,  as  chromic  acid 
or  strong  bromine,  to  the  interior  of  the  uterus,  this  can  be  done  by 
the  same  instrument.     A  few  shreds  of  asbestos  may  be  packed  in  the 


470  ENDOMETRITIS. 

space  between  eyelet-holes,  and  charged  with  the  fluid.  On  ramming 
down  the  piston  the  fluid  exudes. 

Vaginal  lotions  of  tannin,  sulphate  of  zinc,  acetate  of  lead,  or  alum, 
render  important  aid.  There  is  often  some  complication  of  chronic 
inflammation  of  the  fundus  of  the  vagina,  with  ulceration ;  and  it  is 
useful  to  remedy  this  condition.  This  is  the  more  important,  since  the 
patient  can  herself  keep  up  this  treatment.  A  mode  of  medication 
applicable  to  the  vagina  I  have  often  found  useful,  is  to  wrap  about 
twenty  grains  of  alum  in  powder  in  a  pledget  of  cotton-wool ;  and  to 
insert  this  in  the  vagina  daily,  or  every  other  day.  This  contrivance 
acts  in  two  ways ;  first,  there  is  the  astringent,  corrective  action  of  the 
alum,  gradually  acting  as  the  powder  melts  down;  and,  secondly,  the 
cotton  plug  acts  by  keeping  the  irritable  vaginal  walls  from  contact 
and  friction.  It  secures  "rest."  Sometimes,  however,  plugs  act  as 
foreign  bodies,  cause  irritation,  and  are  not  tolerated.  They  should 
not  be  allowed  to  remain  more  than  four  hours.  They  can  be  applied 
by  help  of  the  plug  speculum  figured  at  page  131. 

In  Dublin  and  America  the  fuming  nitric  acid  is  highly  extolled. 
Dr.  Lombe  AtthilP  advises  first  local  bloodletting  by  scarification. 
Then  he  proceeds  to  the  swabbing  the  interior  of  the  uterine  cavity 
with  strong  nitric  acid.  In  order  to  secure  its  due  application,  he 
dilates  the  cervix  uteri  with  a  fagot  of  laminaria-tents ;  then  he  intro- 
duces an  intra-uterine  speculum,  which  makes  a  channel,  protecting 
the  cervix,  through  which  the  charged  swab  can  be  carried  direct  to 
the  fundus  of  the  uterus.  The  uterus  is  drawn  down  and  steadied  by 
seizing  the  os  uteri  with  a  vulsellum.  Dr.  Kidd,  Dr.  Ringland,  Dr. 
Evory  Kennedy,  Dr.  J,  A.  Byrne,  all  speak  highly  of  the  efficacy  and 
safety  of  this  method.  For  my  own  part,  I  feel  compelled  to  repeat 
that  experience  has  amply  proved  that  the  dilatation  by  tents  of  the 
cervix  uteri,  howsoever  necessary  it  may  be  in  some  cases,  is  almost 
invariably  a  painful,  and  sometimes  a  dangerous  proceeding.  The 
action  of  the  nitric  acid,  itself,  I  do  not  doubt  is  useful,  and  as  safe  as 
most  other  agents. 

Constitutional  treatment  should  not  be  neglected.  In  the  acuter 
stages  salines  and  sedatives,  with  a  bland  unstimulating  diet,  should 
be  given.  In  the  stages  of  debility,  when  nutrition  has  become  im- 
paired, and  when  the  nervous  centres  have  suffered  from  long-continued 
impressions  of  pain,  and  the  wear  and  tear  of  illness,  neuralgia,  in  one 
or  more  of  its  numerous  forms,  is  almost  sure  to  be  developed.  Reme- 
dies presumedly  directed  ad  hoc,  are  almost  as  sure  to  fail,  unless, 
indeed,  the  exhausting  disease,  the  endometritis,  be  cured.  But  still, 
the  use  of  tonics  and  other  remedies  calculated  to  improve  nutrition, 
to  procure  ease  from  pain,  to  regulate  the  secretions,  should  go  on 
pari  passu. 

Copaiva,  which  may  be  given  in  the  form  of  capsules,  appears  to 
possess  some  virtue  in  restraining  secretion  from  the  mucous  membrane 
of  the  uterus,  although  it  is  less  to  be  depended  upon  than  in  the  case 
of  the  lungs  or  bladder.     Ergot  and  digitalis  are  also  at  times  useful ; 

'  Dublin  Medical  Journal,  Januarj',  1873. 


TREATMENT.  471 

quinine,  bark,  and  strychnine,  I  think,  are  even  more  so.  These  agents, 
then,  must  not  be  neglected  as  adjuvants. 

Purgatives  become  of  essential  importance.  Saline  aperients,  aloes, 
an  occasional  mercurial  alterative,  generally  combined  with  belladonna, 
give  the  best  results.  Aran  speaks  highly  of  aloetic  enemata.  Indeed, 
no  indication  is  of  more  general  apj)lication  than  that  of  keeping  the 
rectum  free  from  accumulation. 

Exercise  should  be  regulated  by  the  patient's  strength,  and  her  lia- 
bility to  pain.  A  sense  of  weight,  of  oppression,  of  pain  in  the  pelvis, 
extending  down  the  legs,  should  be  taken  as  a  warning  to  rest.  Hip- 
baths and  the  consequent  friction  bring  some  of  the  benefits  of  exercise. 

When  the  active  symptoms  have  been  subdued  by  local  treatment, 
the  stimulating  salines,  sulphur  or  iron  waters  will  be  useful  in  con- 
firming the  cure.  Hip-baths  of  plain  cold  water,  combined  with  vaginal 
irrigation,  often  render  great  service.  But  in  most  cases  warm  baths 
are  safer  and  more  useful. 

There  is  a  form  of  inflammation  of  the  cervix,  chiefly  limited  to  the 
mucous  membrane,  unconnected  with  pregnancy,  which  may  also  be 
called  traumatic.  It  is  the  result  of  undue  or  awkward  sexual  inter- 
course, associated  or  not  with  infection  or  local  poisoning.  Although 
most  frequent  in  young  married  women,  I  have  seen  a  similar  condi- 
tion independent  of  sexual  intercourse.  In  some  of  these  the  cause 
was  obscure ;  in  others  the  disease  ensued  upon  cold  or  violent  exertion. 
The  patient  complains  of  pain  more  or  less  acute,  in  the  centre  of  the 
pelvis,  radiating  to  the  hypogastrium  and  groins.  She  stoops  in  walk- 
ing, in  order  to  relieve  the  pain.  Any  exertion  quickly  induces  such 
pain  and  exhaustion  that  she  is  compelled  to  rest.  There  is  often  some 
degree  of  constitutional  irritation  and  disturbance  of  the  function  of  the 
stomach.  Sometimes  there  is  leucorrha?a;  but  often  the  reply  to  ques- 
tions upon  this  point  is  in  the  negative.  On  examination,  it  may  be 
found  that  there  is  a  copious  accumulation  of  muco-puriform  matter  in 
the  fundus  of  the  vagina,  where  it  lodges,  being  retained  there  as  in  a 
sac  by  the  contraction  of  the  vagina  below.  Such  a  collection  may  be 
voided  unconsciously  during  defecation.  The  rugse  are  prominent, 
angry-red ;  copious,  epithelial  secretion  is  found  between  the  ruga,  and 
viscid  glairy  secretion  is  seen  oozing  from  the  cervix  uteri.  The  mem- 
brane covering  the  vaginal-portion  of  the  cervix  may  be  smooth,  or 
may  present  spots  of  epithelial  abrasion ;  but  it  is  in  either  case  in- 
tensely red,  injected,  and  somewhat  swollen.  This  form  of  disease  not 
uncommonly  induces  vaginismus.  Dyspareuuia  is  often  very  marked. 
The  treatment  consists  in  "  rest."  Injections  of  lead  are  especially 
useful.  In  aggravated  cases,  especially  those  marked  by  vaginismus, 
the  vaginal-rest,  or  a  cotton- wool  plug  soaked  in  glycerin,  renewed 
daily,  will  be  of  essential  service,  and  will  greatly  shorten  the  period 
of  treatment. 

One  form  of  endometritis  leads  to  exfoliation  in  mass  of  the  mucous 
membrane.  This  constitutes  the  dysmenorrhcea  membranacea,  which 
has  been  described  in  Chapter  XXII.  In  some  cases  of  this  kind  I 
have  known  inflammation  affect  the  mucous  membrane  of  the  cervix, 
as  well  as  of  the  body.    The  epithelium  of  the  os  uteri,  and  presumably 


472  ENDOMETRITIS. 

that  of  the  cervical  canal  as  M'ell,  being  thrown  off,  leaving  a  pseudo- 
ulcerated  or  denuded  surface,  although  there  had  been  no  labor. 

If  there  be  a  tubercular  diathesis  the  case  is  more  troublesome  still, 
probably  incurable;  for  tubercularization  is  rarely  limited  to  the 
uterus. 

The  syphilitic  taint  is  commonly  acquired  through  the  gestation  of 
a  diseased  ovum,  and  often  first  becomes  manifest  after  the  birth  of  a 
child,  at  times  showing  marks  of  the  disease,  or,  more  frequently,  after 
the  premature  birth  of  a  dead  child,  or  after  an  abortion. 

The  syphilized  mucous  membrane  is  thickened — constantly  tending 
to  rapid  superficial  decay ;  and  its  regeneration  is  imperfect.  The 
taint  remains,  as  in  the  skin,  for  an  indefinite  time.  Such  a  mucous 
membrane  is  unfitted  to  develop  a  healthy  decidua,  and  yet  it  is  not 
a  bar  to  impregnation.  Hence  conception  after  conception  issues  in 
abortion ;  and  every  time  the  new  mucous  membrane  is  reformed  with 
the  same  characters.  More  or  less  chronic  engorgement  or  inflamma- 
tion of  the  body  of  the  uterus  commonly  attends.  Unlike  the  tuber- 
cular diathesis,  the  syphilitic  commonly  affects  the  cervix  as  well  as 
the  body  of  the  uterus. 

There  is  always  hypersemia,  sometimes  chronic  inflammation ;  and 
the  menstrual  disposition  is  towards  excess  in  loss.  The  appearance 
of  the  vaginal-portion  has  struck  me  in  many  cases  as  being  peculiar, 
so  that  I  have  thought  I  could  recognize  the  syphilitic  complication 
by  the  sight.  But  in  practice  we  are  not  often  obliged  to  trust  exclu- 
sively to  the  local  symptoms.  It  is  rare  that  the  history  and  the  pres- 
ence of  symptoms  in  various  parts  of  the  body  do  not  reveal  the  nature 
of  the  case.  Sore  throat,  fissured  or  ulcerated  tongue,  characteristic 
eruptions  on  the  skin,  falling  of  the  hair,  will  generally  be  found. 

Leucorrhoea,  the  discharge  being  often  more  offensive  than  usual,  is 
a  constant  symptom. 

The  treatment  must  obviously  be  both  constitutional  and  local. 
Iodide  of  potassium,  occasionally  iodide  of  mercury,  bark,  should  be  per- 
sisted in  for  several  months.  A  cure  cannot  be  effected  in  a  few  weeks. 
Baths  of  Yichy  salts,  or  better  still,  the  internal  and  external  use  of 
bromo-iodic  waters,  as  those  of  the  Woodhall  Spa,  Kreuznach,  Carls- 
bad, or  Wiesbaden,  will  render  eminent  service. 

The  best  local  remedies  are  the  iodide  of  lead,  or  iodide  of  mercury 
ointment  applied  inside  the  uterine  cavity.  The  direct  contact  with 
the  diseased  mucous  membrane  I  have  found  especially  beneficial. 
Sometimes  the  part  may  be  touched  with  solid  nitrate  of  silver,  or  a 
small  stick  of  sulphate  of  zinc  may  be  inserted.  All  these  remedies 
are  best  applied  without  the  speculum,  by  means  of  the  tubes  figured 
on  page  129.  The  applications  should  be  made  every  fourth  or  fifth 
day  between  the  menstrual  epochs. 

The  local  treatment  may  be  partly  carried  on  by  the  patient  herself. 
Sulphate  of  zinc  injections  daily  will  be  of  service,  although  they 
touch  the  vagina  and  vaginal-portion  only. 

Should  pregnancy  occur,  and  it  is  to  be  deprecated  until  the  mucous 
membrane  shall  have  recovered  its  soundness,  the  local  treatment  must 
be  stopped.     But  the  constitutional  remedies  should  be  sedulously  per- 


CYSTIC    ENDOMETRITIS.  473 

sistecl  in.  We  may  usefully  combine  with  the  iodide  of  potassium 
five  or  ten  grain  doses  of  chlorate  of  potash.  In  this  way  abortion  is 
sometimes  averted. 

The  submucous  uterine  tissue  becomes  hypertrophied  into  connec- 
tive-tissue outgrowths  (Sarcomata),  which  gradually  form  the  so-called 
fibrous  polypi,  in  whose  interior  are  often  contained  separated  portions 
of  elongated  uterine  glands,  or  gland-tubes,  of  new  formation,  which 
degenerate  into  cysts  [Cysto-sarcoma  adenoides). 

Sometimes  the  uterine  mucous  membrane  degenerates  into  a  more  or 
less  hard,  richly  nucleated,  fibrillous,  callous,  connective-tissue  sub- 
stratum, in  which  the  glands  have  shrunk  away.  Often  it  is  studded 
with  small  cysts,  containing  mucus  or  colloid,  the  remains  of  the  sepa- 
rated portions  of  the  uterine  glands. 

Cystic  Endometritis. 

The  development  of  cystic  tumors  at  the  cervical  orifice  out  of  ob- 
structed glands  is  not  uncommon.  It  is  less  frequent  in  the  cavity  of 
the  uterus,  but  still  it  is  occasionally  observed  as  a  result  of  chronic 
endometritis.  The  utricular  follicles  may,  as  we  have  seen,  be  greatly 
hypertrophied.  They  may  be  seen  as  small  rounded  tumors,  projecting 
as  hemispheres,  or  sometimes  pedunculated ;  their  walls  are  transpar- 
ent ;  they  feel  like  little  resisting  grains,  slightly  elastic.  They  range 
from  the  size  of  a  pin's  head  to  that  of  a  small  nut.  They  contain  a 
transparent  liquid.  They  are  often  associated  with  the  so-called  fun- 
gosities,  granulations,  or  vegetations.  Ch.  Robin  has  shown  that  these 
bodies  are  formed  of  exactly  the  normal  elements  of  the  uterine 
mucous  membrane.  There  is  a  disposition  to  fatty  degeneration  at 
their  base. 

In  some  rare  cases  the  elongation  of  the  uterine  glands  takes  place 
in  both  directions,  that  is,  into  the  uterine  cavity  on  the  one  hand,  and 
into  the  uterine  parenchyma  on  the  other. 

These  little  cystic  growths  sometimes  form  a  cluster,  hanging  round 
the  upper  end  of  the  cervical  canal,  near  the  os  internum ;  or  may  be 
more  or  less  isolated ;  or  they  may  occur  in  groups  or  singly,  near  the 
OS  externum.  When  they  form  in  the  cervix  the  os  externum  is  usu- 
ally patulous,  and  the  finger  passed  into  the  cavity  feels  them  as  rough 
projections,  or  as  soft  pedunculated  bodies  rolling  under  the  finger. 
Sometimes,  as  in  a  case  figured  by  Lancereaux,  these  cervical  cystic 
growths  are  associated  with  a  similar  formation  in  the  body  of  the 
uterus.  In  this  case  the  enlarged  uterus  contained  a  thick  viscid  fluid ; 
its  mucous  membrane  M^as  red,  injected,  had  at  its  fundus  a  mammil- 
lated  mass,  grayish,  formed  of  vascular  connective  tissue,  in  which 
were  found  multiple  cavities  filled  with  clear  serosity. 

These  changes  of  the  mucous  membrane  probably  include  some  of 
the  most  difficult  pathological  and  therapeutical  problems.  The  "  fun- 
gosities,"  "  carnosities,"  "  excrescences,"  so  often  associated  with  some 
degree  of  enlargement  of  the  body  of  the  uterus,  attended  by  hemor- 
rhage, and  inducing  cachexia,  not  seldom,  by  their  obstinacy  and  other 
characters,  simulate  malignant  disease.     Sometimes,  indeed,  there  is 


474  CYSTIC    ENDOMETRITIS. 

good  reason  to  believe  that  the  endometritis  is  dependent  upon,  and 
modified  by,  a  tubercular  or  cancerous  complication.  But  even  apart 
from  such  complication,  the  changes  of  structure  resulting  from  long- 
standing slow  congestion  or  infiamraation  are  exceedingly  troublesome. 

They  may  sometimes  be  distinguished  from  the  malignant  disease 
which  attacks  the  lining  membrane  of  the  uterus  after  the  menopause 
by  this  circumstance :  if  there  have  been  a  distinct  interval  after  the  meno- 
pause, marked  by  absence  of  blood-discharge,  then  the  sudden  appear- 
ance of  hemorrhages  is  strongly  presumptive  of  the  rise  of  malignant 
disease.  But  where  during  the  latter  years  there  has  been  persistent 
menorrhagia,  followed  by  hemorrhages  more  or  less  periodical,  without 
any  prolonged  break  to  mark  the  cessation  of  ovarian  life,  although 
the  insidious  invasion  of  malignant  disease  may  be  possible,  the  pre- 
sumption is  greater  in  favor  of  chronic  inflammatory  change  in  the 
mucous  membrane.  Forming  sessile  or  pedunculated  tumors,  they 
resemble,  and  sometimes  may  be,  early  papillary  epithelioma. 

Whether  malignant  or  benign,  a  symptom  which  cannot  be  over- 
looked any  more  than  the  hemorrhage,  is  almost  constant,  that  is,  severe 
pain.  This  I  have  found,  both  when  the  growths  were  in  the  cervix 
and  when  they  were  in  the  proper  cavity  of  the  uterus. 

The  bleeding  is  often  profuse  to  the  extent,  by  its  quantity  and  fre- 
quent recurrence,  of  endangering  life.  When  the  seat  of  the  disease  is 
the  cervix  the  blood  is  sometimes  bright  arterial ;  when  the  seat  is  in 
the  body  of  the  uterus,  and  the  blood  is  liable  to  temporary  or  partial 
retention,  it  may  be  darker,  even  black. 

This  gradual  rise  of  the  affection  towards  the  advent  of  the  meno- 
pause, and  its  comparatively  rare  occurrence  at  an  earlier  age,  supply 
evidence  of  its  slow  development  out  of  chronic  inflammation. 

They  are  not  uncommonly  associated  with  fibrous  tumors  or  polypi 
in  the  body  of  the  uterus,  as  may  be  seen  in  illustrations  in  the  chapter 
on  those  affections. 

As  already  said,  the  body  of  the  uterus  is  almost  invariably  enlarged ; 
its  walls  are  thickened.  This  commonly  induces  some  signs  of  pro- 
lapsus, but  flexion  is  by  no  means  a  necessary  concomitant.  I  think  I 
have  more  frequently  observed  anteversion.  The  enlargement  of  the 
womb  is  the  result  of  slow  hyperplastic  process.  There  is  generally  a 
degree  of  softness  of  structure.  Increased  vascularity  or  congestion, 
aggravated  by  ovarian  stimulus,  leads  to  menorrhagia,  now  and  then 
amounting  to  alarming  flooding.  Dyspareunia  commonly  attends,  and 
intercourse  is  sometimes  the  excitino;  cause  of  hemorrhage.  The  uterus 
is  found  by  touch  to  be  increased  in  bulk  and  weight,  and  to  be  unusu- 
ally sensitive.  The  sound  will  often  cause  bleeding,  and  more  pain 
than  is  usual.  The  speculum  shows  tumefaction  and  vascularity  of  the 
vaginal-portion ;  a  patulous  state  of  the  cervical  canal,  and  blood  or 
mucus  issuing  from  the  uterus. 

The  systemic  symptoms  are  the  expression  mainly  of  the  losses  of 
blood,  and  of  the  impairment  of  the  functions  of  nutrition  and  inner- 
vation, consequent  on  ansemia  and  local  irritation.  This  exhaustion 
and  the  attendant  pain  will  commonly  give  the  patient  a  peculiar,  worn, 
haggard  expression  of  countenance. 


CYSTIC    ENDOMETRITIS.  475 

The  first  indication  in  treatment  is  usually  the  urgent  one  to  arrest 
bleeding.  To  carry  this  out  the  most  effectual  means  are  the  topical 
application  of  perchloride  or  persulphate  of  iron  in  styptic  strength,  or 
rather  concentrated  chromic  or  nitric  acid.  These  agents  may  be  carried 
into  the  uterine  cavity  on  a  sponge  or  strip  of  linen,  mounted  on  a 
whalebone  probang,  or  on  a  glass  pencil,  through  a  speculum,  if  the 
canal  of  the  cervix  is  open  and  straight  enough;  or  better  still,  we  may 
pursue  the  method  already  described,  of  Dr.  Atthill.  In  the  contrary 
case  it  may  be  necessary  first  of  all  to  dilate  the  cervix  by  sponge  or 
laminaria  tents.  Indeed,  the  rule  laid  down  in  the  chapter  on  "  Hemor- 
rhages "  to  "  obtain  and  maintain  free  patency  of  the  cervical  canal " 
applies  strictly  to  this  case.  So  true  is  this,  that  in  many  cases  the 
mere  artificial  dilatation  will  check  the  hemorrhage.  Dr.  Routh^  even 
affirms  that  the  action  of  "  the  sponge-tent  itself  suffices  to  cause  absorp- 
tion and  diminution  of  volume  of  the  uterus." 

When  the  hemorrhage  has  been  checked,  tonics,  as  strychnine, 
quinine,  ergot,  will  be  useful.  The  diet  should  be  light ;  stimulants 
should  be  sparingly  given. 

The  introduction  into  the  cavity  of  the  uterus  of  solid  sulphate  of 
zinc  every  fourth  or  fifth  day,  nitrate  of  silver  and  nitrate  of  potash 
fused  in  equal  parts,  chlorate  of  potash,  iodide  of  potassium,  and  iodide 
of  mercury,  will  in  turn  often  be  of  eminent  service. 

In  obstinate  cases  where  the  above  or  other  topical  applications  fail, 
the  expediency  of  removing  the  diseased  tissue  must  be  considered. 
It  was  in  such  cases  that  Recamier  practiced  the  operation  of  scraping 
off  the  excrescent  fungosities  by  a  curette.  The  proceeding  seems  a 
bold  one,  even  rough ;  but  then  the  condition  of  the  patient  is  serious. 
Undoubtedly  patients  have  been  rescued  from  imminent  danger  by  it. 
I  affirm  this  from  my  own  experience  in  several  cases.  In  this  aflPec- 
tion,  as  in  undoubted  malignant  disease,  it  is  the  surface,  the  papillary 
projections,  which  are  the  immediate  source  of  the  bleeding.  When 
the  superficial  stratum  is  removed  the  bleeding  is  usually  arrested,  at 
least  for  a  time. 

Fig.  97  represents  Marion  Sims's  curette,  which  I  have  found  a  very 
convenient  instrument.  It  has  two  sizes,  one  at  either  end  of  a  stem 
about  ten  inches  long. 

Fig.  98  represents  R^camier's  curette.  The  two  forms  may  be  con- 
veniently united  in  one  instrument,  so  that  either  end  may  be  used. 
The  curette  held  in  the  right  hand  is  passed  into  the  body  of  the  uterus, 
guided  by  a  finger  of  the  left  hand  applied  to  the  os  uteri,  the  fundus 
being  supported  by  the  hand  of  an  assistant  above  the  symphysis.  The 
subacute  edge  of  the  curette  is  then  drawn  down  over  the  entire  inter- 
nal surface,  so  as  to  break  down  and  detach  any  projecting  masses. 
Sometimes  small  pisiform  or  pyriform  bodies,  like  minute  vascular  or 
mucous  polypi,  are  brought  away.  By  injecting  a  light  stream  of 
water  these  bodies  will  be  washed  out,  and  may  be  collected  in  a  cloth 

^  "  Cases  of  Menorrhagia  treated  by  Injection,  or  the  Removal  of  the  Uterine 
Mucous  Membrane  by  the  Gouge."  By  C.  H.  F.  Eouth,  M.D.,  Obstetrical  Trans., 
vol.  ii. 


476 


CYSTIC    ENDOMETEITIS. 


applied  to  the  vulva,  for  examination.  It  is  not  generally  necessary  to 
apply  anything  to  the  surface  after  the  curette  has  done  its  work.  But 
there  is  better  security  against  bleeding,  and  probably  useful  action 
upon  the  diseased  surface,  by  mopping  with  nitric  or  carbolic  acid. 


Marion  Sinis's  curette. 


When  applying  the  nitric  acid  it  is  necessary  to  introduce  the  specu- 
lum— my  modification  of  Neugebauer's  1  have  found  the  most  conveni- 
ent— and  to  draw  down  the  os  into  a  direct  line,  by  seizing  the  anterior 
lip  with   Sims's  hook.     The   os  being  thus  held  open,  the  probang 


Eecamier's  curette. 


charged  with  the  acid  is  easily  introduced,  without  touching  other 
parts.  Absolute  rest  is  essential.  There  is  of  course  room  for  appre- 
hension, lest  metritis  follow.  The  operation  should  not  be  resorted  to 
except  when  milder  and  safer  proceedings  have  failed  to  relieve  urgent 
symptoms.  Occasions  arise  when  timidity  on  the  part  of  the  surgeon 
will  seal  the  patient's  fate;  and  when  his  duty  is  calmly  to  balance  the 
dangers  of  expectancy,  and  of  resort  to  even  a  doubtful  remedy.  I 
therefore  think  that  it  ought  not  to  be  condemned.  But  it  should  be 
adopted  only  in  a  limited  class  of  obstinate  cases  and  with  all  due  cir- 
cumspection. 

After  this  decisive  course  of  action,  we  have  reason  to  hope  that  a 
healthier  mucous  membrane  will  be  produced.  But  the  truth  must  be 
admitted,  that  the  disease  is  apt  to  return.  This,  however,  may  not 
occur  for  several  months;  and  during  this  time  the  patient  may  suffer 
little  from  hemorrhage  or  other  trouble.  During  this  period  of  inter- 
mission, or  of  apparent  cure,  much  may  be  done  to  bring  down  the 
chronic  congestion  and  tumefaction  of  the  uterus.  Strychnine,  quinine, 
iodide  of  potassium,  even  iodide  of  mercury  will  be  useful.  And,  in- 
ternally, the  application  of  solid  sulphate  of  zinc,  or  of  iodide  of  mer- 
cury in  ointment  will  prove  serviceable. 

Anomalies  of  Consistency. — One  of  the  most  remarkable  is  the  pulpi- 
ness of  advanced  age  coming  on  after  long-continued  mucous  secretions, 
which  disposes  to  apoplexy.  Another  form  of  softening  is  that  ensu- 
ing upon  childbearing,  where  involution  is  arrested  by  marasmus. 
The  mucous  membrane  may  also  become  soft  and  pul])y  in  young  per- 
sons from  repeated  hemorrhage.  From  constant  infiltration  it  swells 
and  disintegrates. 


SENILE    UTERINE    CATAREH.  477 

Abnormal  hardness  of  the  uterus  affects  chiefly  the  vaginal-portion, 
in  consequence  of  the  predominance  of  connective  tissue  in  hypertrophy. 

Senile  Uterine  Catarrh. — I  have  already  adverted  to  this  disease 
when  discussing  the  subject  of  atresia.  It  deserves  separate  considera- 
tion, on  account  of  its  frequency  and  importance.  It  probably  in  most 
cases  is  continuous  from  chronic  metritis  acquired  before  the  meno- 
pause. Notwithstanding  the  disposition  to  uterine  senile  involution 
or  atrophy,  a  change  wliich,  in  some  cases,  may  terminate  that  vascular 
activity  upon  which  inflammation  and  even  secretion  depend,  a  degree 
of  morbid  action  is  often  perpetuated.  The  pelvic  vessels  often  con- 
tinue engorged  after  the  menopause  from  impeded  hepatic  circulation. 
The  uterus  in  these  cases  will  remain  unduly  congested,  and  the  slow 
chronic  inflammatory  process  is  thus  easily  fed. 

This  condition  in  some  cases  will  account  for  the  occasional  apparent 
return  of  the  menstrual  discharge  several  months  after  the  function 
had  been  supposed  to  have  ceased.  This  is  one  form  of  senile  uterine 
hemorrhage.  In  other  cases  there  is  not  so  much  vascular  fulness ; 
yet  the  mucous  membrane  continues  to  throw  off  a  more  or  less  abun- 
dant thin  opaque  mucous  secretion.  The  walls  of  the  uterus  are  usu- 
ally somewhat  thicker  than  usual.  Atrophy  in  fact  has  been  arrested. 
The  cavity  is  almost  always  enlarged.  The  sound  readily  turns  round 
in  it.  The  flaccid  condition  of  the  uterus  disposes  to  flexion,  most  fre- 
quently to  retroflexion  ;  although  it  is  certain  that  in  many  cases  the 
flexion  existed  before,  and  may  have  been  the  cause  of  the  endome- 
tritis. When  this  occurs  there  will  of  course  be  more  or  less  retention 
of  mucosities  in  the  uterus.  And  it  is  to  this  retention  that  some  of  the 
most  marked  symptoms  are  due.  It  brings  about  a  sense  of  fulness, 
weight,  and  oppression,  with  pain  in  the  pelvis.  The  constant  wear 
and  tear  tells  upon  the  nervous  system,  and  often  the  most  distressing 
nervous  phenomena  are  produced.  Mental  despondency  is  the  most 
marked  characteristic. 

In  a  considerable  number  of  cases  I  have  found  complete  closure  of 
the  cervical  canal,  generally  at  either  the  os  internum  or  os  externum. 
The  walls  have  grown  together  by  a  process  compounded  of  inflamma- 
tion and  atrophy.  But  the  uterine  cavity  continuing  to  secrete,  the 
fluids  secreted  accumulate;  and  thus  again  retention  with  its  conse- 
quences ensue.  Expulsive  pains  are  felt,  which  generally  subside,  to 
be  renewed  at  variable  intervals.  In  some  cases  it  is  certain  that  the 
aged  uterus,  not  receiving  the  stimulus  of  menstruation,  and  but  feebly 
responding  to  other  stimuli,  accommodates  itself  to  the  distension. 
Atrophy  progressing,  the  fluid  part  of  the  mucus  may  disappear,  or 
be  retained  without  causing  further  trouble.  But  in  other  cases,  and 
those,  if  I  may  judge  from  my  own  observation,  not  a  few,  the  distress 
does  not  subside.  Advice  is  sought  on  account  of  the  pelvic  suffering, 
or  metrorrhagia.  Then  we  find  the  roof  of  the  vagina  contracting  into 
a  cone,  at  the  apex  of  which  is  a  small  depression,  recognized  as  the  os 
uteri.  There  may  be  little  or  no  projecting  vaginal-portion.  Behind 
this  depression  we  may  feel  the  retroflected  body  of  the  uterus ;  or  this 
part  may  be  in  natural  position.  On  trying  to  pass  the  sound  we  find 
it  soon  meets  with  an  obstruction.     The   os   externum   is   occluded. 


478  LESIONS     OF     CONTINUITY. 

Sometimes  a  little  steady  pressure  with  the  point  of  the  sound  will 
penetrate  the  obstruction.  But  I  have  several  times  found  it  necessary 
to  restore  the  cervical  canal  by  incision  or  puncture.  For  this  purpose 
a  most  convenient  instrument  is  the  sheathed  male  urethral  stricture 
bistoury.  The  probe  end  of  the  sheath  is  filed  off,  so  that  when  the 
end  is  applied  to  the  seat  of  the  os  uteri  the  point  of  the  knife  is  made 
to  protrude  and  penetrate  the  cervix.  This  done,  an  ounce  or  more  of 
muco-purulent  fluid  has  escaped  with  manifest  relief.  To  prevent  re- 
lapse it  is  necessary  to  pass  the  sound  every  now  and  then  ;  and  to 
correct  the  morbid  state  of  the  cavity  a  stick  of  two  grains  of  sulphate 
of  zinc  should  be  introduced  every  four  or  five  days.  By  this  treat- 
ment a  cure  is  commonly  effected  in  a  few  weeks.  The  atrophic  j^ro- 
cess  goes  on  undisturbed. 

One  form  of  this  atresia  is  represented  in  Fig.  92,  page  404. 

Fibroid  tumors  distorting  the  cervical  canal  may  bring  about 
atresia. 

In  chronic  internal  metritis,  especially  in  elderly  women,  Aran  ad- 
vises the  use  of  the  hollow  sound  or  catheter,  as  a  means  of  diagnosis. 
The  retained  mucous  fluids  are  thus  drained  off,  and  their  quality  and 
quantity  may  be  estimated.  The  ordinary  sound  will  not  effect  this 
object.  We  may  use  a  male  silver  or  elastic  sound,  but  the  curve 
must  be  very  moderate.  The  ointment-carrier  (see  Fig.  44,  page  129) 
also  answers  the  purpose.  Dr.  Charles  Hen  nig  sent  to  the  Obstetrical 
Society^s  Exhibition  an  aspirator-tube,  designed  to  draw  out  fluids 
from  the  uterus. 

The  following  remarks  apply  generally  to  the  treatment  of  chronic 
endometritis.  The  exhaustion  wrought  by  disordered  nutrition  may, 
there  is  great  reason  to  believe,  in  some  instances  end  in  the  develop- 
ment of  tubercular  mischief  in  the  lungs.  This  termination  is  not 
surprising,  when  we  remember  that  a  strumous  or  lymphatic  diathe- 
sis is  a  powerful  factor  in  producing  and  in  giving  the  stamp  of  ob- 
stinacy to  chronic  metritis. 

In  some  cases  marked  by  peculiar  obstinacy  there  is,  as  I  have 
already  said,  a  tubercular  condition  of  the  uterine  mucous  membrane. 
For  this  I  doubt  if  there  is  any  cure.  To  pursue  local  treatment  in 
such  a  case,  beyond  perhaps  applying  an  occasional  disinfectant,  would 
be  to  inflict  needless  distress.  It  must  also  become  a  question  how 
far,  when  lung  mischief  has  become  revealed,  it  is  desirable  to  persist 
in  treating  the  uterine  catarrh.  It  should  not,  I  think,  always  be 
given  up.  The  principle  of  curing,  as  far  as  we  can,  every  component 
part  in  a  chain  of  morbid  complications  obtains  here.  But  often  it 
will  be  found  the  most  judicious  course  to  abandon  local  treatment, 
and  to  apply  all  our  care  to  the  general  system,  and  the  alleviation  of 
the  lung-distress. 

Lesions  of  Continuity  of  the  Uterus. — Lacerations  may  occur  in  the 
non-pregnant  uterus.  I  have  carefully  described  the  lacerations  of  the 
pregnant  uterus  in  ray  "  Lectures  on  Obstetric  Operations,"  second 
edition,  1871.  Under  excessive  distension  from  collections  of  blood 
or  mucus,  laceration  has  occurred.  The  uterus  has  also  ruptured  from 
the  presence  of  a  polypus  in  its  cavity. 


PERIMETRIC    INFLAMMATION.  479 

Connective-tissue  new  formation  appears  chiefly  in  the  shape  of 
fibrous  tumor,  of  sarcoma,  and  j^apillary  tumor. 

The  fibrous  tumor — desmoid es  uteri — is  the  most  frequent  of  all 
uterine  growths. 

It  chiefly  affects  the  body  of  the  uterus,  and  more  especially  the 
fundus,  rarely  the  lower  part;  very  seldom  the  cervix  or  vaginal- 
portion. 

It  is  not  seldom  seen  in  company  with  fibrous  polypus,  mucous  and 
vesicular  polypi,  or  with  uterine  cancer,  or  ovarian  cystic  disease. 

The  tumors  will  be  more  especially  described  in  a  future  chapter. 


CHAPTER  XLI. 

PELVIC  CELLULITIS  (PAKAMETKITIS)  :  PELVIC  PEKITONITIS 
(PEKIMETEITIS);  PEKIMETRIC  INFLAMMATION  (PERIUTE- 
EIJSTE  INFLAMMATION)  ;  3IETE0-PEE1T0NITIS. 

The  subject  of  inflammation  of  the  pelvic  tissues  connected  with  the 
uterus  and  its  appendages  has  been  worked  out,  of  late  years,  with 
great  clinical  skill;  and,  I  may  venture  to  add,  with  superfluous 
critical  acumen.  There  is  a  natural  tendency  to  embody  or  condense 
the  new  views  we  arrive  at  as  to  the  essential  pathological  condition, 
by  assigning  to  this  condition  a  new  name.  If  this  name  be  tolerably 
precise  and  descriptive,  it  is  often  readily  accepted  as  the  last  expression 
of  science.  Hence  a  name  is  apt  to  impose  upon  the  learner  the  belief 
that  he  has  caught  the  true  clinical  idea.  And  then,  in  accordance 
with  another  tendency,  the  mind,  satisfied  with  the  seeming  fulness  of 
the  idea  embodied  in  a  new  term,  proceeds  to  eject  every  other  term 
hitherto  associated  with  the  condition  under  discussion  as  false.  Unable 
to  entertain  two  ideas  at  the  same  time,  hastily  concluding  that  one  or 
the  other  must  be  false,  the  one  which  is  presented  in  the  most  attrac- 
tive or  authoritative  manner  is  accepted,  to  the  absolute  exclusion  of 
the  other. 

This  reflection  is  remarkably  illustrated  in  the  history  and  varying 
nomenclature  of  inflammations  of  the  pelvic  structures.  These  inflam- 
mations of  course  remain,  or  continue  to  be  reproduced,  as  they  always 
have  been.  New  names  may  represent  new  theories,  but  the  clinical 
facts  are  unchanged.  It  is  these  which  it  is  important  to  understand. 
It  is  to  be  feared  that  new  names  have  tended,  rather  to  obscure  these 


480  PERIMETmC    INFLAMMATION. 

facts  than  to  elucidate  them.  In  attaching  too  much  importance  to 
names,  that  is,  in  allowing  the  mind  to  be  dominated  by  the  theories 
that  names  represent,  we  are  apt  to  lose  sight  of  the  truth  which  lies  in 
the  rival  names  and  theories.  A  true  theory  and  a  false  theory  are 
antagonistic.  If  we  accept  the  one  we  must,  logically,  reject  the  other. 
But  there  is  no  antagonism  between  two  true  theories.  These  must  be 
reconcilable,  however  widely  observation  and  reasoning  carried  on  in 
different  lines  may  place  them  in  opposition. 

I  will  now  endeavor  to  state  the  case  plainly,  divested  of  all  theory 
or  school-doctrine.  All  the  structures  in  the  pelvis  are  liable  to  inflam- 
mation. It  is  conceivable,  and  true  in  fact,  that  any  one  of  them  may 
be  alone  the  seat  of  inflammation.  It  is  conceivable,  and  true,  that  two 
or  more  of  them  may  be  inflamed  together.  We  have  already  endeavored 
to  trace  the  history  of  inflammation  of  the  ovaries.  Fallopian  tubes,  and 
uterus.  It  remains  to  fill  up  the  account  by  tracing  the  history  of  in- 
flammation of  the  other  adjoining  structures.  What  are  these  struc- 
tures ?  We  are  not  called  upon  in  this  place  to  consider  inflammation 
of  the  rectum,  bladder,  or  vagina,  otherwise  than  incidentally.  The 
structures  with  which  we  are  now  concerned  are  the  cellular  or  con- 
nective tissue,  the  peritoneum,  and  the  broad  ligaments.  No  one 
disputes  that  each  of  these  structures  may  be  the  principal  focus  of 
inflammation.  For  example,  however  we  may  cavil  at  the  term 
"  pelvic  cellulitis,"  we  cannot  deny  that  the  pelvic  cellular  tissue,  that  is, 
the  connective  tissue  in  relation  with  the  uterus  and  broad  ligaments, 
is  liable  to  inflammation.  Paris,  Frarier,  Courty,^  E,  Simon,  Alph. 
Gu^rin,  each  relates  cases  of  distinct  pelvic  cellulitis.  "Pelvic  cellu- 
litis" expresses  this  fact,  and  nothing  more.  Again,  however  we  may 
cavil  at  the  term  "  pelvic  peritonitis,"  we  cannot  deny  that  the  peri- 
toneum which  invests  or  covers  in  the  organs  in  the  pelvis  is  liable  to 
inflammation.  "  Pelvic  peritonitis,"  then,  is  a  good  term,  as  express- 
ing this  fact.  So  again,  at  the  bedside  we  are  often  called  upon  to 
speak  of  inflammation  of  the  broad  ligaments.  When  we  so  speak  we 
do  not  pretend  to  define  rigorously  which  of  the  constituents  of  the 
broad  ligaments — connective  tissue,  vessels,  muscular  fibres,  or  perito- 
neum— is  especially  the  seat  of  inflammation.  Although  undoubtedly 
inflammation  may  begin  in  the  vessels,  or  in  the  connective  tissue,  or 
in  the  peritoneuui,  w^e  shall  rarely  find  an  instance  in  which  inflamma- 
tion does  not  involve  the  proximate  tissues  more  or  less.  We  are 
therefore  generally  compelled  to  speak  of  inflammation  of  the  broad 
ligaments  in  the  aggregate.  It  is  scarcely  possible  for  the  vessels  and 
connective  tissue  inclosed  in  a  thin  lamina  between  the  folds  of  the 
peritoneum  to  be  inflamed,  without  involving  the  peritoneum.  Now, 
the  cellular  tissue  is  chiefly  situated  on  either  side  of  the  uterus,  sur- 
rounding the  vessels  and  nerves  at  the  line  of  ingress  and  egress ;  in 
front  of  the  lower  third  of  the  uterus  where  its  cervix  is  attached  to  the 
bladder ;  behind  the  uterus  and  vagina,  where  a  stratum  connects  these 
organs  with  the  peritoneum  and  rectum ;  and  between  the  peritoneal 
folds  of  the  broad  ligaments.     All  this  cellular  tissue  may  be  described 

1  See  Courtv's  "  Maladies  de  I'Uterus."  &c.     1870. 


PERIMETRIC    INFLAMMATIOjSr,  481 

as  continuous ;  and  therefore  inflammation  beginning  at  one  part  may 
spread  to  the  rest.  The  part  which  seems  most  isolated  from  the  rest 
is  that  mass  of  tissue  which  connects  the  cervix  uteri  with  the  base  of 
the  bladder.  Accordingly  this  part  is  occasionally  the  seat  of  inflam- 
mation^ which  may  run  its  course  without  spreading  beyond  its  own 
limits,  and  wdthout  implicating  the  peritoneum,  at  least  in  any  impor- 
tant degree.  But  the  like  limitation  can  hardly  be  predicated  of  any 
other  part  of  the  cellular  tissue.  The  vessels  whiclj  so  often  carry  the 
cause  of  inflammation,  and  the  peritoneum,  are  in  such  intimate  relation 
with  the  cellular  tissue  at  the  sides  of  the  uterus,  and  with  that  in  the 
broad  ligaments,  that  the  serous  investing  membrane  can  rarely  escape. 

We  thus  come  to  the  general  conclusion,  one  amply  borne  out  by 
clinical  observation,  that  pelvic  cellulitis,  pure  and  simple,  is  a  rare 
affection.  Thus  when  we  use  the  term  "pelvic  cellulitis,"  in  the  great 
majority  of  cases  we  use  a  term  which  only  expresses  a  part  of  the 
morbid  process.     So  far  then  the  term  is  open  to  objection. 

Again,  the  peritoneum  covering  in  the  pelvic  organs  being  continuous 
with  the  abdominal  peritoneum  is  subject  to  inflammation  spreading  to 
it  from  the  abdomen.  With  this  secondary  inflammation  we  are  not 
now  concerned.  The  pelvic  peritoneum  is  far  more  frequently  the 
primary  seat  of  inflammation,  which,  beginning  here,  may  spread  to 
the  abdominal  portion  of  the  serous  membrane.  Now,  if  we  ask  how 
it  is  that  the  pelvic  peritoneum  is  so  prone  to  inflammation,  we  shall 
find  a  plain  answer  in  the  clinical  and  pathological  facts.  There  is  not 
— I  say  this  with  some  confidence,  yet  not  without  reserve — evidence 
to  show  that  inflammation  begins  in  the  pelvic  peritoneum ;  inflamma- 
tion in  this  membrane  is  excited  by  a  morbid  condition  of  the  structures 
which  it  invests.  That  is,  where  the  uterus,  tubes,  ovaries,  vessels,  and 
cellular  tissue  are  healthy,  scarcely  any  cause,  other  than  extension  of 
inflammation  from  the  abdominal  peritoneum,  can  produce  inflamma- 
tion of  the  pelvic  peritoneum.  The  chief  exceptions  to  this  proposition 
are  those  cases  where  inflammation  is  kindled  by  some  irritating  matter 
poured  into  the  peritoneal  cavity,  and  which  by  gravitation  or  prox- 
imity to  the  seat  of  injury  is  chiefly  concentrated  in  the  dependent 
pouches  of  the  pelvic  peritoneum.  And  even  in  these  cases  where  the 
peritonitis  takes  its  rise  in  conditions  independent  of  inflammation  or 
disease  of  the  pelvic  organs,  the  cellular  tissue,  at  least  in  some  degree, 
soon  becomes  involved. 

We  come  then  to  the  further  conclusion,  that  pelvic  peritonitis,  pure 
and  simple,  is  also  a  very  rare  affection. 

Disease  rarely  consents  to  the  limits  which  medical  nomenclature 
would  assign  to  it.  All  terms,  therefore,  wdiich  profess  to  be  precise 
definitions  are  pretty  sure  to  be  fallacious.  If  then  we  conclude  that 
the  terms  "  pelvic  cellulitis  "  and  "  pelvic  peritonitis,"  which  have  been 
for  some  time  in  use,  imperfectly,  and  therefore  inaccurately,  represent 
what  we  find  at  the  bedside,  the  more  recent  terms,  which  are  equally 
exclusive,  must  be  equally  fallacious. 

The  more  recent  terras  to  which  reference  is  made  are  those  intro- 
duced by  one  of  the  greatest  of  living  pathologists,  one  from  whose 

31 


482  PERIMETRIC    INFLAMMATION. 

authority  no  one  can  dissent  without  hesitating  long.  Virchow^  pro- 
poses to  substitute  the  terms  "  Perimetritis  "  and  "  Parametritis."  He 
bases  the  first  term  on  the  analogy  with  "  Pericarditis."  Just  as  the 
serous  investment  of  the  heart  may  be  the  special  seat  of  inflammation, 
so  may  the  serous  investment  of  the  uterus.  Perimetritis,  then,  may 
be  taken  as  the  equivalent  of  pelvic  peritonitis.  It  is  difficult  to  see 
any  sufficient  grounds  for  preferring  the  new  to  the  older  term.  The 
analogy  with  the  heart  is  surely  strained.  The  heart  is  completely, 
solely,  and  everywhere  closely  invested  by  its  own  exclusive  serous 
membrane;  the  pericardium  reflected  upon  itself  forms  a  special  bag, 
within  which  the  heart  alone  is  inclosed.  The  pericardium  then  en- 
joys absolute  immunity  from  inflammation  extending  from  the  serous 
investment  of  other  organs  ;  and  comparative  immunity  from  inflamma- 
tion extending  from  any  other  source  than  the  heart  itself.  Pericarditis 
probably,  like  pleurisy,  chiefly  owes  its  origin  to  offending  matters  car- 
ried in  the  blood.  Peritonitis  undoubtedly  often  owes  its  origin  to 
like  conditions.  But  the  pelvic  peritoneum,  whilst  not  free  from  lia- 
bility to  inflame  under  general  toxaemic  influences,  is  exposed  to  in- 
flammation from  other  causes.  These  are,  as  we  have  seen,  metritis, 
salpingitis,  oophoritis,  pelvic  cellulitis,  inflammation  of  the  vessels 
carrying  septic  matter  from  the  uterus,  irritating  matters  poured  into 
the  peritoneal  sacs  of  the  pelvis,  and  extension  of  inflammation  of  the 
abdominal  peritoneum.  The  serous  investment  of  the  body  of  the 
uterus  forms  a  very  small  part  of  a  membrane  which  has  numerous 
other  relations,  and  which  is  therefore  exposed  to  numerous  sources  of 
disease.  If  the  term  "  perimetritis "  be  limited  to  the  few  square 
inches  of  peritoneum  which  covers  the  body  of  the  uterus,  it  only  ex- 
presses a  very  small  part  of  the  clinical  case.  Inflammation  so  limited 
is  extremely  rare.  If  the  term  be  made  to  embrace  inflammation  of 
the  serous  membrane  of  the  tubes,  ovaries^  and  broad  ligaments,  then 
it  is  strained  beyond  its  etymological  meaning,  and  is  wholly  inade- 
quate for  clinical  purposes.  The  correlative  terms,  "  perisalpingitis" 
and  "  perioophoritis,"  proposed  to  supplement  "  perimetritis,"  prove  the 
inadequacy  of  this  latter  term.  Themselves,  they  are  hardly  worthy 
of  discussion. 

I  submit,  then,  that  there  is  no  sufficient  reason  for  adopting  the 
term  "  Perimetritis." 

The  term  "  Parametritis,"  intended  to  describe  inflammation  of  the 
cellular  tissue  in  the  neighborhood  of  the  uterus,  is  also  open  to  objec- 
tion. It  is  less  comprehensive  than  "  pelvic  cellulitis."  It  is  not 
alone  the  tissue  immediately  surrounding  the  uterus  which  is  exposed 
to  inflammation.  Indeed,  inflammation  of  the  cellular  tissue  is  rarely 
so  limited.  Nor  does  it  even  always  begin  in  this  part.  The  inflam- 
mation in  the  broad  ligament  often  begins  from  disease  of  the  Fallopian 
tubes  or  ovaries,  and  may  never  re^ch  the  cellular  tissue  near  the 
uterus. 

We  are  driven  then  alike  by  etymology  and  by  clinical  observation 

1  Archiv.  fiir  Pathol.  Anat.  und  Pliys.  1862. 


PERIMETRIC    INFLAMMATION.  483 

to  reject  both  the  terms  "  Perimetritis  "  and  "  Parametritis  "  as  being 
inadequate,  and  not  justified  by  scientific  necessity. 

The  truth  being  that  tlie  pelvic  peritoneum  and  the  pelvic  cellular 
tissue  being  each  liable  to  inflammation,  we  want  the  terms  "  pelvic 
peritonitis  "  and  "  pelvic  cellulitis.'^  And  it  being  also  true  that  in  a 
great,  perhaps  the  greater,  proportion  of  cases,  both  peritoneum  and 
cellular  tissue  are  inflamed  together,  we  want  a  term  which  shall  ex- 
press this  common  affection.  The  term  "  peri-uterine  inflammation," 
adopted  by  Courty,  answers  to  this  want.  It  is  indeed  open  to  an 
objection,  which  not  seldom  meets  us  in  medical  nomenclature,  namely, 
that  it  is  a  discordant  compound  of  Greek  and  Latin.  This  may  be 
avoided  by  substituting  the  term  "  perimetric  inflammation."  In 
adopting  this  term  I  mean  to  include  inflammation  involving  the 
broad  ligaments  and  their  contents. 

This  term  carries  us  back  somewhat  to  the  term  "  Phlegmonous 
intra-pelvic  abscesses,"  adopted  by  Marchal  (de  Calvi),  to  whom  science 
is  indebted  for  the  most  important  of  all  modern  contributions  to  this 
subject.^  His  is  the  great  merit  to  have  shown  that  the  chief  seat  of 
the  puerperal  and  many  other  abscesses  in  women  was  in  the  pelvis. 
He  thus  exploded  the  erroneous  ideas  which  connected  these  inflamma- 
tions with  the  iliac  fossse. 

And  since  perimetric  inflammation  is  so  frequently  consequent  upon, 
and  therefore  complicates,  inflammation  of  the  uterns  or  its  appendages, 
to  express  this  compound  condition  we  want  the  term  "  metro-periton- 
itis." 

The  researches  of  Bernutz^  and  of  MM.  Bernutz  and  Goupil,^  con- 
ducted in  the  most  admirably  philosophical  spirit,  have  been  pre-emi- 
nently useful  in  extending  and  in  correcting  our  knowledge  of  the 
subject.  These  researches  have  demonstrated  that  what  had  hitherto 
commonly  passed  for  pelvic  cellulitis  was  often  pelvi-peritonitis.  The 
phlegmonous  masses  rising  out  of  the  pelvis,  and  extending  into  the 
iliac  foss8e,  so  frequently  met  with  after  labor,  are  shown  to  be,  strictly 
speaking,  not  pelvic  cellulitis,  but  peritonitis.  This  much,  with  some 
qualification,  may  be  granted.  But  it  is  to  be  feared  that  here  again 
is  an  instance  of  one  idea  making  good  its  way  by  driving  out  another 
from  ground  where  both  have  a  common  right.  In  these  post-puer- 
peral cases,  with  which  we  are  the  most  familiar,  because  they  most 
frequently  come  under  clinical  and  post-mortem  observation,  there  is 
almost  always  a  complication  of  cellulitis  and  peritonitis  ;  and,  it  might 
also  be  added,  of  metritis  as  well.  The  peritonitic  element  will,  it  may 
be  admitted,  generally  predominate.  But  the  other  elements  coexist. 
It  appears  to  me  then  that  Bernutz,  whilst  rendering  incontestable 
service  in  calling  attention  to  the  important  part  played  by  peritonitis 
in  these  cases,  has  rather  undervalued  the  other  factors  of  the  disease. 

If  I  may  trust  my  own  clyiical  observations,  which  I  may  fairly 

1  "  Des  absc^s  phlegmoneux  intra-pelviens."     1844. 

2  "  Archives  gen^rales  de  Medecine."     1857. 

'  "  Clinique  inedicale  sur  les  maladies  des  femmes;  Memoire  de  la  pelvi-p^rito- 
nite  et  de  ses  diverses  varietes."     Paris,  1862. 


484  PERIMETRIC    INFLAMMATION. 

say  are  numerous,  and  my  dissections,  which  I  frankly  acknowledge 
are  not  so  numerous  nor  so  exact  as  those  of  Bernutz,  I  should  say 
that  whilst  the  term  "pelvic  cellulitis"  fails  to  express  the  whole 
nature  of  the  case,  still  it  ought  not  to  be  altogether  suppressed  in 
favor  of  "  pelvic  peritonitis." 

In  post-puerperal  perimetric  inflammation,  which  must  serve  for  a 
type  or  illustration  of  other  orders  of  cases  as  well,  there  may  be  dis- 
tinguished three  kinds  : 

1st.  That  kind  which,  as  far  as  we  can  judge,  is  simply  inflam- 
matory. 

2dly.  A  kind  in  which  septicaemia  plays  a  conspicuous  part.  The 
inflammation  is  of  a  low  type.  There  is  a  tendency  to  diffuse,  or 
erysipelatoid  inflammation  and  to  general  systemic  empoisonment. 

3dly.  There  is  a  kind  of  intermediate  between  the  two  preceding, 
in  which  there  is  a  septic  factor,  but  which  is  held  in  abeyance  by  the 
superior  vigor  of  the  blood.  In  these  cases  the  septic  matter  is 
blocked  out  by  the  healthy  blood  coagulating  in  the  efferent  pelvic 
vessels,  and  intercepted  by  the  lymphatic  glands.  In  this  way  the 
system  escapes,  and  the  morbid  influences  are  mainly  concentrated  in 
the  pelvis. 

In  the  first,  or  purely  inflammatory  kind,  the  action  is  chiefly  spent 
upon  the  peritoneum.  These  may  properly  be  called  cases  of  pelvic 
peritonitis.  They  are  analogous  to  the  cases  of  pericarditis  and  of 
pleurisy,  which  supervene  on  a  sudden  impression  of  cold,  when  the 
pericardium  and  pleurae  have  undergone  unusual  strain,  the  blood 
being  also  modified,  under  violent  bodily  exertion.  The  violent  per- 
turbation of  parturition  induces  a  peculiarly  susceptible  condition  of 
the  uterine  and  pelvic  peritoneum,  and  an  alteration  of  the  blood  which 
is  favorable  to  the  development  of  inflammation,  if  an  exciting  cause, 
such  as  cold  or  emotion,  be  applied.  These  are  the  cases  to  which  the 
description  of  Bernutz  more  strictly  applies. 

In  this  order  of  cases  the  peritonitis,  in  many  instances,  does  not 
break  out  until  two  or  three  weeks  or  more  after  labor.  Thus,  a 
young  lady  of  delicate  organization,  suckled  imperfectly  for  seven 
weeks ;  whilst  menstruating  she  went  to  town,  undergoing  great  fatigue, 
and  came  home  with  intense  abdominal  and  pelvic  pain  and  fever. 
Pelvic  peritonitis  had  been  produced.  This  is  not  an  uncommon 
history. 

But  not  even  in  all  these  essentially  inflammatory  cases  is  the  in- 
flammation chiefly  expended  upon  the  peritoneum.  There  is  a  sub- 
order of  cases  which  appear  to  be  essentially  of  traumatic  origin,  in 
which  the  chief,  or  at  least  the  primary,  seat  of  the  inflammation  is  in 
the  perimetric  cellular  tissue.  During  the  passage  of  the  child's  head 
through  the  cervix  uteri  there  is  commonly  laceration  of  the  margin 
of  the  OS,  bruising  of  the  mucous  membrane,  and  of  the  whole  sub- 
stance of  the  neck,  attended  by  a  dragging  or  gliding  movement' of  the 
structures  in  most  immediate  contact  with  the  head  upon  the  deeper 
parts.  The  cellular  tissue  around  the  cervix,  where  cellular  tissue 
most  abounds,  is  especially  contused,  stretched,  vessels  in  it  are  torn, 
efl'usion  of  serum  and  ecchymosis  take  place  in  it.     All  this  I  have  fre- 


PERIMETRIC     INFLAMMATION.  485 

quently  verified  by  actual  inspection.  Everything  is  prepared  for  in- 
flammation. There  is  the  local  injury,  the  effusion.  There  is  the 
altered  blood  charged  with  effete  matters,  hyperinotic,  under  the  influ- 
ence of  pregnancy  and  labor.  An  exciting  cause  alone  is  wanting. 
A  chill  is  often  sufficient.  The  chief  seat  of  the  inflammation  in  this 
case  M'ill  be  the  wounded  cellular  tissue.  In  this  tissue  it  may  run  its 
course,  ending  in  resolution  or  in  abscess ;  and  affecting  the  peritoneum 
slightly,  if  at  all. 

In  the  second  order  of  cases,  characterized  by  the  predominance  of 
a  septic  factor,  the  inflammation  of  the  pelvic  tissues  is  universal.  The 
uterus  itself,  its  bloodvessels  and  lymphatics,  the  cellular  tissue  around 
and  in  the  broad  ligaments,  and  the  peritoneum  are  all  involved  in  a 
low  kind  of  inflammation.  The  inflamed  pelvic  peritoneum  throwing 
out  unhealthy  lymph  which  rapidly  breaks  down  into  pus,  sets  up  the 
like  inflammation  in  every  part  of  the  abdominal  peritoneum  with 
which  it  comes  into  contact.  The  poisonous  matter  may  be  generated 
in  the  woman's  system  under  the  strain  of  labor,  her  blood  becoming 
overcharged  with  noxious  materials,  resulting  from  tissue-changes. 
To  this  order  of  cases  I  have  given  the  name  of  "  autogenetic  puer- 
peral fever."  In  another  order  of  cases  the  poisonous  matter  is  inocu- 
lated, it  comes  from  without.  The  woman,  whilst  in  a  highly  suscep- 
tible .state,  takes  in  the  poison  of  scarlatina  or  some  other  zymotic. 
The  general  infection  of  the  blood  here  acts  as  the  exciting  cause  of 
inflammation ;  and  the  inflammation  will  naturally,  in  the  first  in- 
stance, break  out  in  the  pelvic  tissues,  rendered  suscej)tible  by  trau- 
matic action. 

In  these  cases  again  the  inflammation  will  not  be  limited  to  the  peri- 
toneum. It  will  invade  the  uterus,  cellular  tissue,  and  peritoneum 
alike.  It  must,  however,  not  be  forgotten  that  patients  seized  with 
this,  the  heterogenetiG  form  of  puerperal  fever,  not  seldom  die  of  the 
fever  before  any  marked  local  inflammation  declares  itself.  A  feature 
distinguishing  cases  of  this  order  from  the  first  or  simple  inflammatory 
kind,  is  that  the  disease  commonly  breaks  out  much  earlier,  that  is, 
within  three  or  four  days  after  labor. 

In  the  third,  or  mixed  order  of  cases,  in  which  there  is  a  septic  factor, 
controlled  by  a  comparatively  healthy  state  of  the  blood,  the  inflamma- 
tion begins  in  the  uterine  sinuses  and  lymphatics.  Under  the  com- 
bined influence  of  traumatism,  and  of  blood  somewhat  impaired  by  the 
tissue-changes  of  pregnancy  and  labor,  and  sometimes  of  decomposing 
debris  of  placenta,  membranes,  and  blood-clots  in  the  uterus,  foul  mat- 
ters form  in  the  uterine  cavity,  get  into  the  uterine  sinuses  and  lym- 
phatics, and,  not  arrested  there,  either  from  want  of  contractile  energy 
of  the  uterine  fibre,  or  because,  being  as  yet  too  abundant  for  the  blood 
it  meets  in  its  course  to  segregate  by  coagulation,  it  invades  the  vessels 
in  the  broad  ligaments,  where  further  progress  may  be  stayed  by  the 
formation  of  clots.  This  thrombotic  process  is  generally  attended  by 
inflammation  of  the  perivascular  tissues,  and  of  the  broad  ligaments, 
which  is  pretty  sure  to  involve  the  peritoneum.  If  the  lymphatics  be 
concerned  as  well  as  the  veins,  then  the  phenomena  of  phlegmasia 
dolens  are  developed. 


486  PEEIMETEIC    INFLAMMATION. 

That  the  broad  ligaments  are  chiefly  involved  in  the  majority  of 
these  cases,  seems  proved  by  the  seat  of  the  tumefaction  being  in  the 
sides  of  the  pelvis ;  and  by  the  uterus  itself  remaining  in  many  cases 
apparently  free  from  inflammation.  That  is,  in  this  rather  consider- 
able order  there  is  not  necessarily,  perhaps  not  very  often,  inflamma- 
tion of  the  peritoneal  investment  of  the  body  of  the  uterus ;  that  is, 
there  is  no  perimetritis.     It  is  perimetric  inflammation. 

Trousseau  may  be  cited  as  insisting  upon  the  frequent  complication 
of  phlebitis  with  inflammation  of  the  broad  ligaments.  He  believes 
that  phlebitis  is  the  most  frequent  cause  of  this  inflammation. 

A  very  similar  description  will  apply  to  the  perimetric  inflamma- 
tions supervening  on  abortion.  It  applies  often  very  closely  to  inflam- 
mation of  the  broad  ligaments  leading  to  phlegmasia  dolens,  beginning 
in  cancer  of  the  uterus. 

Hemorrhage  at  the  time  of  labor  or  abortion  powerfully  predisposes 
to  perimetric  inflammation.  The  parts  being  so  predisposed,  compara- 
tively slight  causes  set  up  inflammation.  Amongst  the  most  frequent 
of  these,  is  cold,  usually  so  freely  applied  in  the  form  of  ice,  cold  water 
injections,  cold  douche  to  the  abdomen,  and  other  ways  of  swamping 
the  patient.  Exposure  to  chill  and  of  getting  about  too  soon  are  com- 
mon causes. 

It  deserves  to  be  remembered  that  pelvic  peritonitis  is  not  uncom- 
mon in  the  foetus ;  and  that,  although  it  is,  in  this  case,  often  de- 
pendent upon  conditions  which  lead  to  death,  the  child  may  grow  up, 
and  in  after-life  the  pelvic  organs  may  remain  bound  by  persisting  ad- 
hesions. This  condition,  it  is  highly  probable,  renders  the  subject  un- 
usually liable  to  new  attacks  of  peritonitis  when  the  organs  are  called 
into  functional  exercise. 

Perimetric  inflammations  occurring  in  the  non-pregnant  state,  pre- 
sent features  which  it  is  interesting  to  compare  with  those  which  follow 
labor.  They  follow  the  same  laws.  When  metritis  is  set  up  from  the 
retention  of  decomposing  matters  in  the  body  of  the  uterus,  from  trau- 
matism, as  from  injury  by  the  sound  or  other  instruments,  or  from  an 
intra-uterine  pessary,  the  primary  inflammation  being  in  the  body  of 
the  uterus,  the  secondary  inflammation  will  attack  the  uterine  peri- 
toneum, at  least  chiefly.  On  the  other  hand,  when  the  cervix  is  first 
attacked  by  inflammation,  resulting  from  operations  performed  upon 
it,  by  the  irritation  of  tents  or  other  causes,  the  nearest  tissue  external 
to  the  cervix — that  is,  the  cellular  tissue  in  which  the  vessels  run — 
will  first  catch  the  inflammatory  process,  and  perimetric  cellulitis  will 
be  the  chief,  perhaps  the  exclusive,  secondary  affection. 

Another  illustration  of  this  proposition  may  be  found  in  the  history 
of  epithelioma  of  the  cervix.  This  disease  in  its  progress  long  respects 
the  body  of  the  uterus;  as  it  extends,  it  involves  the  perimetric  cellular 
tissue,  and  it  is  often  late  before  the  peritoneum  is  attacked. 

Perimetric  inflammation,  apart  from  pregnancy,  is  not  uncoramou 
as  the  consequence  of  suppressed  or  disordered  menstruation.  During 
this  function,  we  have  in  miniature  the  conditions  of  pregnancy  and 
labor.  The  gorged  organs,  caught  in  a  state  of  intense  susce]itibility, 
are  exceedingly  prone  to  become  softened.     In  these  cases,  dissections 


PERIMETEIC    INFLAMMATION.  487 

of  Bernntz  and  Goupil  prove  incontestably  that  it  is  the  peritoneum 
which  is  the  chief  seat  of  inflammation.  They  found  the  cellular  tis- 
sue perfectly  free.  This  is  no  subject  for  surprise.  Abortion  and 
arrested  menstruation  differ  from  labor  in  this  particular :  the  cervix 
escapes  all  traumatic  injury ;  the  seat  of  functional  activity,  and  there- 
fore of  susceptibility,  is  the  body  of  the  uterus,  the  tubes,  and  the  ova- 
ries. Hence  the  body  of  the  uterus,  the  tubes,  and  ovaries  are  prima- 
rily subject  to  inflammation,  and  inflammation  of  these  organs  is 
readily  followed  or  attended  by  inflammation  of  their  investing  mem- 
brane. 

Beruutz  and  Goupil  affirm,  and,  if  I  may  be  permitted  to  express 
my  own  opinion,  prove,  that  pelvic  peritonitis,  acute  or  chronic,  takes  its 
origin,  in  a  vast  proportion  of  cases,  in  disease  of  the  uterus,  tubes,  and 
ovaries ;  that  peritonitis  is,  therefore,  secondary,  symptomatic  ©f  other 
disease.  They  further  maintain,  and  here  also  I  concur  in  their  con- 
clusion, that  inflammation  of  the  pelvic  peritoneum  proceeds  more  fre- 
quently from  inflammation  of  the  tubes  and  of  the  ovaries  than  from 
inflammation  of  the  uterus. 

Although  facts  enough  exist  to  prove  that  metritis,  acute  or  chronic, 
may  excite  inflammation  of  the  peritoneum,  yet  it  is  a  remarkable 
clinical  fact  that,  common  as  chronic  metritis  is,  the  uterus  rarely  be- 
comes fixed,  as  it  would  be  were  its  peritoneum  to  become  inflamed. 

Although  pelvic  peritonitis  in  a  large  proportion  of  cases  is  caused 
by  disease  of  the  uterus,  tubes,  or  ovaries,  or  is  secondary  upon  pelvic 
cellulitis,  it  is  nevertheless  true  that  there  is  a  large  class  of  cases  in 
which  this  membrane  is  the  seat  of  primary  inflammation.  For  clini- 
cal purposes  it  is  important  fully  to  recognize  this  distinction.  The 
history  of  the  two  orders  of  cases  is  often  strikingly  contrasted.  The 
secondary  form  following  upon  diseases  of  the  pelvic  organs  is  of  course 
preceded  by  the  symptoms  which  belong  to  those  diseases ;  the  perito- 
nitis is  an  epiphenomenon,  declaring  itself  in  the  course  of  another 
disease ;  its  special  characters  often  make  their  appearance  gradually, 
even  insidiously,  being  for  a  time  masked  by  those  of  the  original  dis- 
ease. On  the  other  hand,  the  primary  peritonitis  makes  its  appear- 
ance suddenly;  it  is  ushered  in  by  acute  and  severe  symptoms,  often  by 
shock  or  collapse,  and  other  signs  of  traumatism  or  local  injury.  Such 
is  the  history  of  peritonitis  caused  by  the  escape  of  offending  matter 
from  the  Fallopian  tube,  either  running  from  its  fimbriated  extremity, 
or  from  bursting  or  perforation  of  its  walls ;  from  bursting  or  perfora- 
tion of  an  ovarian  cyst  or  abscess ;  from  rupture  of  the  uterus,  or  of  an 
extra-uterine  gestation-cyst ;  from  effusions  of  blood  into  the  perito- 
neum ;  from  perforation  of  the  intestine ;  from  rupture  of  a  dermoid 
cyst. 

Even  in  some  cases  of  this  class  the  symptoms  are  not  marked  by 
suddenness  of  invasion  or  by  great  severity  at  first.  For  instance, 
when  an  ordinary  ovarian  cyst  or  a  dermoid  cyst  undergoes  perfora- 
tion, the  amount  of  irritating  matter  escaping  into  the  peritoneal 
cavity  may  be  small,  and  the  consequent  peritonitis  will  be  limited  and 
subacute. 

Pelvic  peritonitis  may,  like  inflammation  of  the  peritoneum  of  the 


488  PELVIC    INFLAMMATION. 

abdominal  intestines,  arise  from  1,  tubercular  affections;  2,  cancerous; 
3,  traumatic. 

Encysted  serous  peritonitis  may  appear  to  be,  and  sometimes  is,  as- 
sociated with  antecedent  pelvic  disease.  But  it  may  be  independent. 
I  have  related  one  characteristic  example  in  the  chapter  on  the  "Diag- 
nosis of  Ovarian  Tumors/'  at  page  318. 

The  connection  of  some  unilateral  pelvic  or  abdomino-pelvic  abscesses 
with  a  pelvic  origin  is  sometimes  obscure.  We  make  out  clearly  enough 
an  abscess,  and  even  define  its  limits ;  but  dissection  only  can  reveal 
the  cause  of  the  peritonitis,  the  products  of  which  envelop  and  shut 
out  from  observation  the  offending  disease.  This  is  illustrated  in  the 
case  related  at  page  319,  in  which  a  small  ovarian  cyst  was  found  im- 
bedded in  a  peritoneal  abscess,  or  rather  a  congeries  of  communicating 
suppur£?ting  cavities. 

Perimetric  inflammation  is  rare  after  the  menopause.  This  fact 
confirms  the  modern  view  that  this  inflammation  takes  its  rise  almost 
invariably  from  the  inflamed  uterus,  tubes,  or  ovaries.  This  proposi- 
tion, although  generally  true,  is  however  often  affirmed  too  absolutely. 
Malignant  disease,  especially  of  the  body  of  the  uterus;  chronic  me- 
tritis, depending  upon  stenosis  or  flexion  ;  the  various  forms  of  hyper- 
trophy of  the  mucous  membrane  attended  with  hemorrhage,  are  very 
liable,  especially  on  rough  surgical  treatment,  to  lead  to  perimetric  in- 
flammation. It  may  also,  as  I  have  seen,  result  from  local  violence, 
such  as  too  frequent  subjection  to  sexual  intercourse. 

Bernutz  gives  a  valuable  summary  of  the  cases  observed.  Of  99 
cases  of  pelvi-peritonitis — 


.„  ,  r  35  after  delivery  at  term. 

43  were  puerperal.  |    8  after  abortion. 


28  were  blennorrhagic. 
20  were  menstrual. 

(  3  after  venereal  excess. 

I   2  after  syphilitic  disease  of  cervix. 

„  ^  ,.  2  after  use  of  the  sound. 

8  were  traumatic.  j   ^  ^^^^^  ^j^^  ^^^^  ^f  ^  ^^^^-^^^  ^^^^^^^  ^^_ 

\  ployed  in  a  case  of  membranous  ulce- 

[  ration  of  the  cervix. 

Peritonitis  meretricum. — When  gonorrhoeal  infection  is  the  starting- 
point,  the  course  is  usually  as  follows  :  The  poison,  acting  first  at  the 
point  of  contact,  lights  up  inflammation  of  the  vaginal  and  cervical 
raucous  membrane.  This  spreads  to  the  mucous  membrane  of  the 
body  of  the  uterus,  thence  along  the  Fallopian  tubes.  The  ovaries  are 
very  commonly  engaged.  In  the  case  of  gonorrhoea,  Dr.  Matthews 
Duncan  says,  "he  has  never  seen  pelvic  inflammation  come  on  without 
the  presence  of  ovaritis  in  addition,  and  as  the  ovaritis  follows  the 
endometritis,  so  the  latter  is  itself  a  consequence  of  the  original  vagin- 
itis." In  some  of  these  cases,  proof  has  been  obtained  that  the  perito- 
nitis was  immediately  caused  by  the  escape  of  infected  pus  from  the 
fimbriated  ends  of  the  tubes.  But  in  many  cases,  probably,  the  peri- 
toneal coat  of  the  tubes  and  ovaries  becomes  inflamed,  consequent  upon 
the  inflammation  of  these  orsrans. 


PELVIC    INFLAMMATIOJSr.  489 

Mr.  Giles,  in  an  interesting  communication/  relates  three  cases  in 
which  peritonitis,  the  result  of  gonorrhoea,  broke  out  after  childbirth. 
It  must  not,  however,  be  concluded  that  the  peritonitis  of  prostitutes 
is  always  traceable  to  infection.  In  many  instances  there  can  be  little 
doubt  that  it  is  due  to  the  wilful  suppression  of  menstruation  by  the 
local  application  of  cold,  and  to  other  forms  of  exposure  and  violence. 

I  have  known  firm  masses,  the  result  of  pelvic  peritonitis,  following 
on  incision  of  the  cervix  uteri  for  dysmenorrhoea  and  sterility,  last  for 
over  three  years.  One  such  case  I  saw  in  consultation  with  Dr.  Gus- 
tavus  Murray.  The  illness  dated  from  the  operation  performed  three 
years  before  by  Professor  Simpson.  She  had  got  about  too  soon, 
caught  cold,  and  inflammation  followed.  Since  then  she  had  suffered 
constant  pelvic  pain,  increased  on  exertion ;  there  was  oozing  of  san- 
guineous mucous  discharge,  and  dyschezia.  The  cervix  remained 
patulous,  engorged  ;  the  body  of  the  uterus  was  deviated  to  the  left ;  a 
hard  mass  surrounded  the  cervix,  fixing  it  immovably.  Examining 
by  rectum,  when  the  finger  reaches  the  level  of  the  uterine  neck,  it  is 
encountered  by  a  narrowing  of  the  rectal  canal,  barely  admitting  the 
finger ;  all  round  was  a  hard  mass,  which  fixed  the  rectum  to  the  sacrum 
behind,  and  to  the  uterus  in  front.  She  was  treated  with  pessaries  con- 
taining mercury  and  iodine,  and  other  measures ;  but  her  recovery  Dr. 
Murray  attributed  principally  to  the  use  of  the  Wood  hall  Spa  water. 

When  the  opportunity  occurs  of  examining  the  subject  of  pelvic 
cellulitis  in  the  early  stage,  we  may  find  a  lax  condition  of  the  connec- 
tive tissue  ;  its  meshes  infiltrated  with  serum,  lemon-colored,  and  limpid, 
or  turbid  and  brownish,  from  being  stained  with  blood  or  mixed  with 
pus.  When  the  affection  is  the  result  of  labor,  there  is  commonly 
ecchymosis  from  the  rupture  of  small  vessels. 

At  a  later  stage,  the  watery  part  of  the  serous  effusion  has  disap- 
peared ;  there  is  a  firm,  more  or  less  circumscribed  tumefaction,  which 
on  section  exhibits  reddish  points,  and  evidence  of  hyperplasia. 

In  some  cases,  comparatively  rare,  pus  is  found  in  the  phlegmonous 
swelling.  But  almost  always  when  this  is  the  case  the  peritoneum  is 
involved,  and  the  appearances  are  lost  in  those  characteristic  of  peri- 
tonitis. 

The  chief  character  of  peritonitis,  of  course,  is  plastic  effusion.  But 
this  is  preceded  by  intense  vascular  injection  of  the  membrane.  It  is 
bright  with  punctate  stellate  and  arborescent  injections,  and  it  is  often 
uniformly  red. 

The  membrane  has  lost  its  glistening  smoothness;  it  looks  villous 
or  granular.  This  condition  probably  lasts  only  a  few  hours.  Plastic 
lymph  is  quickly  thrown  out  over  the  whole  inflamed  membrane,  and 
glues  opposing  surfaces  together.  It  is  common  to  find  the  ovaries  and 
tubes  enveloped  in  a  mass  of  yellowish  lymph,  more  or  less  solid,  and 
united  to  the  peritoneal  lining  of  the  iliac  fossse,  the  summit  of  the 
bladder,  the  anterior  wall  of  the  lower  part  of  the  abdomen,  and  the 
front  of  the  rectum.  The  fundus  of  the  uterus  is  the  part  that  most 
frequently  escapes.     As  in  life  this  part  can  often  be  felt  and  made 

1  British  Med.  Journal,  1871. 


490  PELVIC    INFLAMMATION. 

out  distinct  from  the  firm  tumefactions  on  either  side  or  behind  it,  so 
after  death  we  often  find  it  cropping  out  comparatively  unaiFected 
from  the  fibrinous  conglomerations  of  the  sides  and  hollow  of  the  pelvis. 

At  a  stage  more  advanced  in  progress,  but  often  even  earlier  in  point 
of  time,  evidence,  more  or  less  extensive,  of  suppuration  will  be  found. 
Where  there  was  a  septic  factor,  the  lymph  may  be  found  in  flakes, 
dirty  red  or  yellow,  adhering  loosely  to  a  dull-red  peritoneum ;  easily 
breaking  down,  this  lymph  will  be  seen  pultaceous,  semifluid,  puru- 
lent. In  the  half-circumscribed  cavities  formed  between  the  imper- 
fectly adhering  peritoneal  surfaces,  a  dirty  turbid  serum  collects;  or, 
in  some  cases,  the  lymph  seems  to  have  no  plastic  property  at  all ;  then 
on  being  opened  streams  of  dirty  serum  and  pus  flow  out  from  the 
general  peritoneal  cavity. 

In  the  stage  of  recent  effusion,  the  parts  can  be  separated  by  break- 
ing down  the  still  soft  agglutinations.  The  ovaries  or  tubes  or  uterus, 
in  which  the  inflammation  probably  began,  will  then  be  seen  red  or 
dull  on  their  peritoneal  aspect,  generally  swollen  beyond  their  normal 
bulk,  and  fuller  of  blood.  At  a  later  stage,  but  still  not  remote  from 
the  beginning,  the  effusions  found  will  be  increased  in  bulk  and  solidity. 
The  organs,  especially  those  of  the  pelvis,  will  be  so  buried  in  the  con- 
solidated masses  of  effused  matter,  that  only  by  tedious  dissection  can 
they  be  traced  and  isolated;  often  the  ovaries  will  be  glued  to  the  pos- 
terior wall  of  the  uterus. 

If  a  case  in  life  correspond  to  the  above  description,  recovery  by 
resolution  may  still  occur.  The  swelling  seems  to  melt  away,  and  the 
only  post-mortem  evidence  of  what  has  gone  before  are  dull-white 
strings  or  bands  tying  the  ovaries  and  tubes  to  the  sides  or  posterior 
surface  of  the  uterus,  or  to  surrounding  structures. 

Perimetric  or  Pelvic  Abscess. — In  many  cases  suppuration  takes  place. 
Various  estimates,  fairly  open  to  all  the  objections  that  invalidate  most 
statistical  operations  performed  upon  pathological  histories,  have  been 
made  to  express  the  proportion  of  cases  which  end  in  suppuration.  It 
is  certainly  large,  probably  much  exceeding  those  which  end  in  reso- 
lution. McClintock,  out  of  seventy -seven  cases  of  puerperal  pelvic 
cellulitis,  found  thirty-seven  end  in  suppuration,  with  discharge  of  pus; 
twenty-four  burst  or  were  opened  externally ;  six  discharged  through 
the  vagina ;  five  through  the  anus ;  and  two  burst  into  the  bladder. 
The  termination  in  suppuration  is  liable  to  be  overlooked.  Pus  escap- 
ing into  the  rectum,  or  even  into  the  vagina,  may  not  be  noticed,  or,  if 
observed,  may  not  always  be  set  down  to  the  right  source.  These  un- 
detected suppurations  naturally  go  in  a  statistical  table  to  swell  the 
number  of  cures  by  resolution. 

The  clinical  physician  will  form  a  much  more  correct  prognosis  as 
to  the  advent  or  not  of  suppuration,  by  weighing  the  characters  of  the 
case  before  him.  If  there  be  septicaemia ;  if  the  patient  be  of  strumous 
or  lymphatic  diathesis  ;  if  she  be  reduced  by  hemorrhage ;  if,  in  short, 
the  individual  conditions  be  of  a  depressing  kind,  the  probability  of 
suppuration  is  vastly  increased. 

Generally,  but  not  always,  in  this  event  a  fresh  increment  of  the 
febrile  symptoms  is  observed.     Shivering  or  rigor  occurs :  the  pulse  is 


PELVIC    INFLAMMATION.  491 

subdued  in  power;  sometimes  vomiting  is  excited.  These  mark  the 
first  entry  of  septic  matter  into  the  circulation,  and  constitute  the  stage 
of  shock.  The  characteristic  is  depression.  Then  come  the  signs  of 
reaction.  The  pulse  is  accelerated,  the  temperature  rises.  _  If  the  amount 
of  septic  empoisonraent  be  great,  signs  of  attempt  at  elimination  appear. 
The  poison,  carried  like  almost  all  poisons  to  the  intestines,  irritates 
the  mucous  membrane  and  causes  diarrhoea ;  and  perhaps  vomiting  is 
again  excited.  This  is  the  stage  of  irritation  or  elimination.  If  only 
one  moderate  dose  of  the  poison  is  imbibed,  the  signs  of  constitutional 
irritation  quickly  subside ;  but  if,  as  often  happens,  fresh  doses  con- 
tinue to  be  imbibed,  the  symptoms  of  shock,  reaction,  and  elimination 
will  recur  in  regular  order.  This  dependence  upon  the  repeated  dosing 
with,  or  accumulation  of  poison,  is  remarkably  proved  by  the  cessation 
of  these  signs  when  the  purulent  collection  bursts  or  is  artificially 
opened. 

Suppuration  goes  on,  in  many  cases  for  two  or  three  or  four  weeks 
before  the  pus  breaks  through  its  investing  sac.  This  event  is  achieved 
in  one  or  more  of  three  chief  directions :  1,  through  the  skin;  2, 
through  a  mucous  membrane  ;  3,  into  the  serous  sac  of  the  peritoneum. 
In  some  cases  imperfect  and  temporary  relief  only  is  obtained  on  the 
discharge  of  pus.  The  hard  tumefaction  in  the  pelvis  subsides  but 
slightly.  Hectic  or  irritative  fever  continues.  Pus  continues  to  flow 
in  more  or  less  remittent  or  intermittent  discharge;  and  sometimes 
successive  purulent  collections  form,  and  burst  at  intervals,  extending 
over  weeks,  months,  and  even  years,  until  the  patient  sinks  exhausted. 
In  some  cases  of  this  class,  happily  the  most  frequent,  the  suppu- 
rative action  at  length  ceases,  the  cavities  contract,  the  solid  deposits 
gradually  become  absorbed,  and  the  recovery  may  be  complete,  even 
the  adhesions  disappearing.  But  patient  and  physician  must  be  pre- 
pared for  a  tedious  course  of  treatment. 

Where  the  septic  element  has  been  inconsiderable,  and  especially 
where  the  inflammation  has  been  excited  by  disease  of  the  tube  or  the 
ovary  proceeding  slowly,  or  only  inflicting  upon  the  peritoneum  a  suc- 
cession of  slight  injuries,  repeated  at  long  intervals,  the  pelvic  organs 
may,  as  in  more  acute  cases,  be  found  imbedded  in  thick  masses  of 
hard  brawny  effusion,  involving  the  rectum  and  the  superincumbent 
small  intestines  and  omentum.  This  condition  may  last,  kept  up  or 
extended  by  occasional  accessions  of  fresh  inflammation,  for  many 
months,  or  even  years.  This  is  the  case  especially  when  the  inflamma- 
tion is  excited  by  a  diseased  ovary,  cystic  or  dermoid.  But  sooner  or 
later,  under  the  irritation  of  the  advancing  disease,  or  of  some  acci- 
dental intercurrent  cause,  suppuration  comes  on.  The  pus  forming  in 
the  substance  of  the  effused  mass,  commonly  beginning  at  the  surface 
or  in  the  substance  of  the  diseased  organ — by  a  process  incident  to  the 
disease,  one  of  the  events  of  which  is  bursting  or  perforation — forms 
an  abscess,  or  a  congeries  of  purulent  collections.  Up  to  a  certain  time 
an  abscess  thus  formed  may  be  fairly  encysted  or  isolated  by  effusions 
which  shut  it  off"  from  the  healthy  portion  of  the  peritoneal  sac.  The 
imprisoned  pus  may  even  undergo  a  transformation  which  ends  in 
absorption.     But  in  the  majority  of  cases  the  sac  of  the  abscess,  extend- 


492  PELVIC    INFLAMMATION. 

ing  its  adhesions  by  eccentric  action,  effects  a  consolidation  with  some 
structure  through  which  a  communication  can  be  made  with  the  ex- 
terior. Thus  a  pelvic  abscess  will  make  its  way  to  the  external  surface 
through  the  skin,  or  into  the  intestine,  bladder,  vagina,  or  rectum ;  or 
unfortunately  failing  in  these  directions,  it  may  perforate  its  own  sac, 
and  pour  its  contents  into  the  peritoneal  cavity.  In  this  latter  event 
we  shall  have  the  ordinary  phenomena  of  "abdominal  shock,"  often 
fatal  speedily  ;  and  if  not  so,  then  followed  by  peritonitis,  from  which 
the  patient  may  or  may  not  recover. 

If  the  pus  work  its  way  out  by  the  skin,  the  place  of  election  is 
most  commonly  the  iliac  region  above  Poupart's  ligament.  Before 
this  happens  there  will  have  been  a  history  of  irritative  fever,  marked 
generally  by  rigors  more  or  less  distinct,  by  small  pulse,  ranging  from 
100  to  120,  by  temperature  running  up  to  101°  F.,  102°  F.,  or  103° 
F. ;  by  sweats ;  occasionally  by  diarrhoea.  The  hard,  somewhat  ellip- 
tical mass,  becomes  softer,  doughy  ;  near  the  skin,  a  patch  at  first  red, 
then  bluish,  appears ;  iluctuation  becomes  distinct ;  and  then,  if  the 
abscess  be  not  opened,  it  bursts. 

Sometimes  the  abscess  points  nearer  to  the  median  line  below  the 
umbilicus.  This  is  more  likely  to  be  the  case  if  the  cause  of  the  peri- 
tonitis be  a  dermoid  ovarian  cyst.  Where  the  inflammation  takes  its 
rise  deep  in  the  pelvis  by  the  side  of  the  vagina,  it  will  sometimes  find 
an  exit  by  the  outlet  of  the  pelvis  through  the  perineum.  I  have  seen 
several  examples  of  this  in  puerperal  cases.  In  these  the  evacuation 
has  been  preceded  by  great  distress  from  the  intra-pelvic  pressure  on 
the  bladder  and  nerves.  It  has  also  made  its  way  by  the  sacro-sciatic 
notch,  or  by  the  side  of  the  anus. 

I  believe,  however,  the  route  most  frequently  selected  is  the  vagina. 
An  oj)ening  is  made  through  the  roof,  mostly  behind  or  to  one  side  of 
the  cervix  uteri.  This  issue,  as  well  as  that  by  the  rectum,  is  some- 
times overlooked.  The  pus  escaping  perhaps  gradually  is  not  distin- 
guished from  the  other  discharges.  When  the  inflammation  is  retro- 
uterine, the  pus  will  almost  always  make  its  way  by  the  roof  of  the 
vagina  or  by  the  rectum,  just  as  a  retro-uterine  hsematoccle  will  do. 
I  have  known  one  or  two  cases  in  which  the  abscess  opened  into  the 
cervix  uteri. 

In  the  majority  of  cases,  discharge  of  pus,  either  by  the  skin  or  by 
a  mucous  canal,  is  followed  by  recovery.  Pus  continues  to  escape  by 
the  opening  for  some  days,  becoming  thinner  and  more  serous.  In 
most  instances  the  discharge  ceases  in  about  twenty-one  or  twenty-eight 
days ;  in  some  even  earlier.  A  notable  diminution  of  the  swelling, 
relief  from  pain,  and  subsidence  of  the  irritative  fever  take  place  almost 
immediately.  The  rigors  caused  by  the  absorption  of  ichor  into  the 
blood  cease  when  the  matter  finds  a  vent  externally. 

But  occasionally  abscess  after  abscess  points  in  different  places,  or 
sinuses  keep  open,  and  continue  to  drain  off  the  secretions  formed  in 
the  suppurating  cavities.  These  cavities  seem  to  be  prevented  from 
closing  by  the  rigid  walls  composing  them  being  fixed  to  the  sides  of 
the  pelvis  or  to  the  intestines.  An  exhausting  suppuration  then  goes 
on,  lasting  for  months  and  even  for  years,  until  the  sufferer  sinks  from 


PELVIC    INFLAMMATION.  493 

inanition,  the  wear  and  tear  of  pain,  and  the  gradual  impairment  of 
vital  functions.  These  cases  of  protracted  suppuration  are,  I  believe, 
mostly  the  result  of  inflammations  set  up  by  the  perforation  of  ovarian 
cysts,  or  of  an  extra-uterine  gestation  cyst,  or  a  dermoid  cyst  into  the 
vagina  or  the  rectum  or  some  higher  part  of  the  intestine. 

But  I  have  seen  similar  cases  which  followed  upon  labor  and  abor- 
tion, after  surgical  operations  upon  the  uterus,  and  after  wearing  a  fixed 
intra-uterine  pessary. 

The  protracted  intermittent  course  of  some  of  these  suppurating 
cases  is  partly  explained  by  the  multilocular  character  of  the  abscesses 
or  suppurating  cavities.  These  burst  successively.  Perhaps  the  sup- 
puration in  one  compartment  sets  up  suppurative  action  in  the  rest, 
and  so  on.  How  these  multiple  abscesses  form  is  probably  accounted 
for  by  the  irregular  shape  and  the  movements  of  the  organs  which  form 
the  framework  or  scaffolding  of  the  peritonitic  efi'usions.  The  intes- 
tinal folds  and  convolutions  form  endless  recesses  and  projections,  and 
the  plastic  layers  which  invest  them  will  almost  necessarily  follow,  to 
a  great  extent,  these  recesses  and  projections ;  whilst  the  incessant  ver- 
micular movements  and  the  alternations  of  distension  and  collapse  of 
the  coiled  intestinal  tube,  acting  whilst  the  effused  matter  is  still  soft, 
will  leave  irregular  spaces,  divided  partially  or  completely  by  septa 
running  in  various  directions.  These  hollow  irregular  spaces  will  in 
the  first  place  be  filled  with  serum,  or  sero-purulent  fluid,  which  at  a 
later  time  is  replaced  by  pus.  When  the  solvent  process  of  suppura- 
tion has  set  in,  the  septa  gradually  break  down ;  the  pus-containing 
spaces  are  fused  together  more  or  less  completely.  But  the  process  is 
tedious,  and  it  may  be  long  before  it  is  complete. 

This  irregular  multilocular  arrangement  will  also  account  for  the 
fact  that  perimetric  abscesses  sometimes  open  in  several  directions. 
Thus  we  may  see  an  abscess  first  make  an  exit  at  the  iliac  region ; 
then,  successively,  it  will  burst  in  the  rectum  and  vagina. 

When  such  abscesses  with  thick  walls,  not  capable  of  collapsing 
under  atmospheric  pressure,  burst  or  are  opened,  air  is  sometimes 
drawn  in.  Decomposition  of  retained  pus  and  blood  ensues,  so  that 
the  discharge  becomes  extremely  offensive.  The  sac,  which  hitherto 
emitted  a  dull  sound  on  percussion,  will  now  be  resonant.  To  a  cer- 
tain extent,  often  effectual,  pressure  by  well-regulated  com^^resses  will 
supplement  the  failure  of  atmospheric  pressure,  in  keeping  the  walls  of 
the  empty  sac  in  contact. 

One  possible  termination,  happily  rare,  of  which  I  do  not  remember 
having  seen  an  unequivocal  example,  is  sloughing  or  gangrene.  Gri- 
solle^  describes  it  as  follows :  "  Gangrene  is  scarcely  ever  observed 
except  in  abscesses  consecutive  to  mortification  of  the  csecum  or  of  its 
appendix,  and  to  the  escape  of  stercoraceous  matters  into  the  neighboring 
cellular  tissue.  I  do  not  believe  that  gangrene  has  ever  been  observed 
in  abscesses  of  spontaneous  origin,  which  are  developed  in  the  sub- 
peritoneal cellular  tissue.  If,  on  the  contrary,  the  inflammatory  en- 
gorgement, although  spontaneous,  is  subjacent  to  the  fascia  iliaca,  this 

1  Arch.  G6n.  de  Medecine,  iii  serie,  tome  iv. 


494  PELVIC    INFLAMMATION. 

may  produce  there  a  true  strangulation  of  the  inflamed  parts ;  and  it 
will  be  sufficiently  common  to  see  in  those  subaponeurotic  abscesses 
the  fibres  of  the  iliac  muscle  blackish,  softened,  and  exhaling  a  fetid 
odor.  No  symptom  can  produce  a  sure  diagnosis  of  this  unfortunate 
termination ;  but,  when  issue  is  given  to  the  effused  matter,  it  exhales 
a  fetid  odor,  and  brings  with  it  gas,  faeces,  and  bits  of  cellular  tissue, 
of  muscles,  and  of  mortified  tendons-  One  can  understand  that  death 
should  be  the  consequence  almost  inevitably  of  such  disorders." 

I,  however,  once  tapped  an  encysted  serous  peritonitic  effusion  giv- 
ing issue  to  a  small  quantity  of  fecal  matter,  foul  gas,  and  horribly 
stinking  serum,  which  ended  in  recovery. 

Matthews  Duncan  mentions  as  one  "  peculiarity  of  pelvic,  and  prob- 
ably of  perimetric  abscess  only,  that  some  have  no  tendency  to  burst 
at  all.  He  has  repeatedly  opened  such  abscesses,  whose  existence  cer- 
tainly dated  several  years  before  his  seeing  them,  and  which  showed 
no  tendency  to  point  in  any  direction."  Such  abscesses  are  occasion- 
ally found  in  the  dead-house.  One  was  recently  observed  in  a  woman 
who  died  shortly  after  admission  into  my  ward.  I  had  recognized  in 
her  a  pelvic  peritonitis  six  years  before.  The  inflammation  and  sup- 
puration were  found  to  have  arisen  around  a  dermoid  cyst. 

The  course  that  perimetric  inflammations  run,  and  the  pathological 
appearances,  will  vary  according  to  the  parts  involved ;  the  compli- 
cation with,  or  absence  of,  septicsemia  ;  the  diathesis  or  constitutional 
state  of  the  patient;  the  treatment  and  other  accidental  circumstances. 

In  puerperal  cases,  I  have  satisfied  myself  that  perimetric  inflamma- 
tion, including  cellulitis,  is  especially  prone  to  arise  in  women  of  stru- 
mous diathesis.  The  same  subjects  are  particularly  prone  to  inflam- 
mation and  abscess  of  the  breast.  I  have  little  doubt,  although  I 
have  not  made  out  the  fact  with  equal  distinctness,  that  the  same  di- 
athesis also  disposes  powerfully  to  like  inflammation  in  the  non-preg- 
nant state.  In  women  of  this  constitution  lymph  is  rapidly  and  freely 
thrown  out,  forming  large  tumefactions.  The  effused  matter,  more 
readily  than  in  sound  constitutions,  degenerates  into  pus.  Dissections 
at  different  stages  of  perimetric  inflammation  appear  to  me  to  prove 
that  it  is  not  always,  perhaps  not  even  generally,  the  plastic  or  semi- 
coagulated  lymph  which,  in  the  first  place,  is  transformed  into  pus. 
There  is  commonly  a  considerable  quantity  of  thin  serous  fluid  which 
becomes  inclosed  by  the  plastic  eifusion,  forming  a  cyst  single  or 
many-celled  around  it.  It  is  this  serous  fluid  which  forms,  as  it  were, 
the  focus  of  the  phlegmon,  which  becomes  turbid  and  purulent.  Very 
soon  no  doubt  the  innermost  layer  of  the  plastic  investment  breaks 
down  in  part,  and  contributes  to  the  purulent  collection,  helping  to 
form  the  abscess. 

That  this  plastic  investment  does  give  way  is  proved  by  the  abscess 
bursting  or  perforating. 

The  effusion  sometimes  takes  place  with  great  rapidity,  as  in  the 
following  not  rare  case :  A  young  lady,  who  had  been  delivered  of  her 
first  child  about  two  months,  and  had  returned  to  her  usual  avocations, 
took  a  long  walk,  came  home  fiitigued  to  her  husband,  was  next  day 
seized  with  intense  pain  in  the  lower  abdomen  and  vomiting ;  consti- 


PELVIC    INFLAMMATION.  495 

pation  and  tympanites  followed.  On  the  fifth  day,  I  found  the  uterus 
set  fast  in  a  mass  of  firm  eifusion ;  the  bowel  also  was  so  compressed 
that  there  was  nearly  complete  obstruction  for  nine  days.  Under  rest, 
opium,  and  enemata  she  got  well. 

In  a  number  of  cases,  very  difficult  to  estimate,  the  inflammation 
terminates  in  resolution.  The  effused  consolidated  masses  of  plastic 
matter  gradually  disappear.  As  this  process  goes  on,  the  uterus  recovers 
its  mobility,  if  not  entirely,  to  a  great  extent.  The  finger  begins  to 
travel  around  the  vaginal-portion.  The  subjective  symptoms  become 
moderated. 

This  process  usually  takes  several  weeks,  even  months,  for  its  com- 
pletion. In  a  considerable  proportion  of  cases  I  have  seen  the  Avhole 
process  completed  in  eight,  ten,  or  twelve  weeks.  But  the  last  stage  often 
lingers  longer  still.  In  not  a  few  cases,  when  the  bulk  of  the  effusion 
has  melted  away,  there  remain  cellular  adhesions  which  may  restrain 
the  movements  of  the  uterus,  and  bind  it  down  in  various  directions. 
Thus,  adhesions  between  uterus  and  bladder  will  produce  anteversion; 
adhesions  in  the  retro-uterine  pouch  will  produce  retroversion  ;  and  we 
may  find  lateral  inclination  from  ovario-uterine  and  alar  adhesions. 

These  adhesions  undoubtedly  often  practically  disappear — that  is, 
under  the  constant  strain  of  the  pelvic  organs  in  their  functional  move- 
ments, the  adhesions  incessantly  stretched  undergo  atrophy  complete 
or  partial,  so  that  they  no  longer  impede  the  uterus.  In  the  case  of 
retro-uterine  adhesions,  I  have  often  accelerated  their  atrophy  by  the 
use  of  a  lever-pessary,  which,  lifting  up  the  fundus  uteri,  puts  these 
bands  on  the  stretch.  One  very  efficient  cause  of  the  disappearance 
of  these  uterine  adhesions  is  pregnancy.  The  uterus  enlarging,  drags 
and  attenuates  them,  so  that  they  undergo  atrophy.  On  the  other 
hand,  they  sometimes  last  an  indefinite  time,  bindiiig  the  uterus  down 
in  various  abnormal  positions,  impeding  this  organ  in  its  natural  move- 
ments, and  thus  leading,  as  Madame  Boivin  insisted,  to  abortion.  The 
ovaries,  which  possess  much  more  limited  natural  movement,  and  are, 
moreover,  smaller  and  less  rigid  bodies,  are  not  so  capable  of  exerting 
a  strain  upon  adhesions,  and  are  consequently  more  frequently  doomed 
to  perpetual  bondage. 

Aran  examined  fifty-three  women  who  died  in  his  wards  with  ref- 
erence to  this  point.  He  found  adhesions  in  twenty-nine.  The  adhe- 
sions were  twice  as  common  in  women  who  had  had  children  as  in 
women  who  had  not.  These,  of  course,  are  selected  cases  dying  in  a 
special  gynsecological  ward,  and  cannot  represent  the  general  propor- 
tion of  adhesions. 

I  have  had  the  opportunity  of  watching  the  course  of  one  case  of  ad- 
hesions with  requisite  precision.  A  young  woman  was  admitted  into 
my  ward  with  retro-uterine  hsematocele.  The  blood-mass  made  its 
way  through  the  roof  of  the  vagina,  and  on  several  occasions  we  saw 
blood  oozing  through  the  opening.  I  passed  a  probe  three  inches  into 
it.  When  the  opening  closed  the  tumor  gradually  disappeared,  and  it 
was  found  that  the  body  of  the  uterus  was  pulled  back,  and  held  in 
that  position  by  adhesions.  Six  months  later  the  uterus  had  nearly 
recovered  under  the  gradual  lifting  action  of  a  Hodge  pessary. 


496  PELVIC    INFLAMMATION. 

When  the  uterine  adhesions  are  persistent  and  short,  binding  the 
uterus  down  tightly,  they  may  be  the  source  of  severe  pain.  They 
may  keep  up  congestion  or  chronic  metritis.  And  so  long  as  adhe- 
sions remain  there  is  a  liability  to  renewed  attacks  of  peritonitis.  This 
disposition  to  relapses,  or  the  "rechublements"  of  French  authors,  is 
always  to  be  borne  in  mind  in  the  antecedent  stages  whilst  the  inflam- 
matory effusions  are  still  thick  and  hard. 

The  sym;ptoms  of  perimetric  inflammation  are  generally  compound. 
In  order  of  time,  signs  of  disease  of  the  uterus,  tubes,  or  ovaries  com- 
monly take  precedence.  Then  follow  those  of  perimetric  inflamma- 
tion. And  these  are  for  the  most  part  severe  enough  to  overwhelm 
and  obscure  those  of  the  original  disease.  This  addition  of  perimetric 
inflammatory  signs  is  usually  more  or  less  sudden.  It  is  marked  by 
acute  intra-pelvic  pain  ;  more  or  less  shock,  according  to  the  cause ;  ac- 
celeration of  pulse  to  120  or  130 ;  heat  of  skin,  the  temperature  rising 
to  103°  F.,  104°  F.,  or  even  105°  F. 

There  is  a  sense  of  fulness  and  pressure,  sometimes  of  bearing-down. 
The  bladder  and  rectum  are  often  disturbed  in  their  functions.  Tym- 
panites, the  result  of  a  kind  of  paralysis  of  the  intestines  whose  peri- 
staltic movements  seem  to  be  instinctively  restrained  in  order  to  avoid 
pain,  is  a  common  symptom.  This  induces  constipation,  which  is  fur- 
ther caused  by  the  narrowing  by  compression  of  the  rectum,  and  by 
the  inability  to  exert  effectually  the  expulsive  movement  necessary  to 
defecation.  Some  amount  of  dysentery  is  not  uncommon.  Colic  pains, 
tormina,  flatulence,  are  often  exceedingly  distressing. 

The  bladder  symptoms  are  often  distressing,  but  are  not  constant. 
There  is  dysuria,  frequent  call  to  pass  water,  an  unsatisfied  sense  of 
the  bladder  having  been  emptied.  This  distress  is  partly  due  to  the 
interference  with  the  contractile  action  of  the  bladder,  and  with  the 
abdomino-pectoral  act  of  expulsion,  and  partly  to  the  irritating  quality 
of  the  urine.  This  is  often  loaded  with  lithates  and  mucus.  If  an. 
abscess  be  about  to  burst  into  the  bladder,  the  dysuria  increases,  and 
not  uncommonly  there  is  retention  of  urine.  When  the  bursting 
has  been  effected,  of  course  pus  will  be  voided  with  the  urine.  Reten- 
tion may  also  precede  the  bursting  of  an  abscess  into  the  rectum  or 
vagina. 

The  ovario-uterine  function  is  variously  affected.  Sometimes  there 
is  metrorrhagia.  This  is  especially  the  case  when  there  is  concomitant 
metritis  or  subinvolution  of  the  uterus  with  abrasion  of  the  mucous 
membrane  of  the  cervix.  But,  not  uncommonly,  even  in  post-partum 
cases,  in  which  subinvolution  is  a  tolerably  certain  attendant  condition, 
menstruation  is  scanty  or  suspended. 

The  secretion  of  milk  is  generally  suspended  either  quickly  or  gradu- 
ally. In  spite  of  the  mother's  anxiety  to  keep  it  up,  it  falls  off*;  it  is 
rather  exceptional  for  it  to  last  out  the  course  of  the  disease;  and  still 
more  rarely  is  injudicious  to  make  the  attempt. 

When  the  seat  of  the  inflammation  is  in  one  side  of  the  pelvis  the 
thigh  is  commonly  kept  slightly  flexed  to  relieve  the  pain  which 
extension  by  stretching  the  inflamed  structures  produces.  This  causes 
the  patient  to  limp  on  the  affected  side  when  walking.     This  lameness 


PELVIC    INFLAMMATION.  497 

is  SO  characteristic  that  I  have  often  diagnosed  lateral  pelvic  inflamma- 
tion to  my  class  on  seeing  a  woman  enter  the  consulting-room  with  the 
ausemic  aspect  following  parturition,  and  this  painful  limp. 

In  some  cases  the  patient  finds  she  cannot  get  the  heel  to  the  ground. 
In  not  a  few  cases  one  or  both  legs  swell  soon  after  labor,  constituting 
the  earliest  sign  to  attract  attention. 

Sciatica  on  the  side  of  the  eifusion  is  a  symptom  I  have  several  times 
observed.  In  one  the  pain  along  the  sacral  plexus  of  the  left  side  was 
very  severe,  and  underwent  exacerbations  marked  by  recurrent  sup- 
purations, over  a  period  of  twelve  years.  The  sciatica  disappeared 
when  the  disease  was  cured. 

When  suppuration  is  proceeding,  the  sense  of  intra-pelvic  tension 
and  of  pain  is  increased. 

In  some  puerperal  cases  I  have  observed  pelvic  inflammation  to  be 
complicated  w^ith  metritis.  This  indicates,  I  believe,  a  strumous  or 
leucophlegmatic  diathesis. 

The  Diagnosis. — The  objective  signs  are  made  out  by  abdominal, 
vaginal  and  rectal  touch.  Palpation  over  the  lower  i:)art  of  the  abdomen, 
especially  if  the  hand  be  pressed  into  the  pelvic  cavity,  gives  rise  to 
acute  pain.  There  is  often  some  degree  of  tympanites ;  and  almost 
always  tension  of  the  abdominal  muscles,  excited  by  the  dread,  even 
more  than  by  the  act,  of  examination.  In  the  early  stage  no  very 
marked  tumefaction  or  irregularity  may  be  felt  in  the  pelvic  brim;  but 
very  soom  a  firm  mass,  more  or  less  rounded  or  cylindrical,  is  made 
out  in  one  or  other,  or  in  both  sides  of  the  pelvic  brim ;  and  as  the  dis- 
ease continues,  this  tumefaction  extends  out  of  the  pelvis,  spreading 
laterally  and  forwards  into  the  iliac  fossae,  bulging  out  above  Poupart's 
ligament,  and  sometimes  rising  as  high  as  the  level  of  the  umbilicus. 
This  swelling  is  hard,  brawny,  tolerably  uniform,  cylindrical.  At 
an  early  stage  the  skin  can  be  moved  over  it,  but  later,  especially  if  the 
process  be  tending  to  suppuration,  the  abdominal  wall  becomes  one 
with  the  tumefaction  underneath. 

The  shape  and  limits  of  the  tumor  rising  out  of  the  pelvis  can  usu- 
ally be  defined  by  the  hand  pressing  in  the  abdominal  wall  above,  and 
getting  even  a  little  way  behind  the  tumor.  By  percussion  the  evidence 
thus  obtained  may  be  checked  and  extended.  An  area  of  dulness  will 
correspond  with  the  tumefaction  behind  the  abdominal  wall,  whilst 
resonance  will  disclose  the  position  of  the  intestines. 

The  vaginal  touch  gives  the  most  decisive  evidence.  The  examining 
finger  entering  the  vagina  is  first  conscious  of  increased  heat  and  puffi- 
ness  of  the  walls.  The  os  uteri  is  reached  much  more  readily  than  in 
the  ordinary  state,  because  an  almost  invariable  efifect  of  the  perimetric 
inflammation  is  to  bring  the  uterus  down  to  a  lower  level.  The  situa- 
tion of  the  OS  uteri  is  usually  near  the  centre  of  the  pelvis.  This  is 
the  case  when  the  chief  seat  of  inflammation  is  in  the  broad  ligaments 
or  in  the  sides  of  the  pelvis.  If  one  side  be  chiefly  affected,  the  cervix 
may  be  pushed  over  towards  the  opposite  side.  But  if  the  case  be  one 
of  retro-uterine  cellulitis  and  peritonitis,  the  uterus  is  pushed  bodily 
forwards,  coming  sometimes  so  close  to  the  symphysis  pubis  as  to  com- 
press the  neck  of  the  bladder,  and  cause  retention  of  urine. 

32 


498 


PELVIC    INFLAMMATION. 


In  post-puerperal  cases  the  os  uteri  is  generally  more  or  less  patulous. 
Surrounded  as  it  is  by  inflammatory  effusion,  contraction  and  involu- 
tion are  impeded.  Feeling  round  the  margin  of  the  os  uteri,  we  com- 
monly fail  to  define  accurately  the  usually  projecting  vaginal-portion. 
Instead  of  the  hemispherical  or  conical  smooth  mass,  merging  at  the 
fundus  of  the  vagina  into  soft  yielding  tissue,  we  find  hard  brawny 
bumi^s  occupying  the  summit  of  the  vagina,  encircling  the  os  down  to, 
or  even  below  its  level,  preventing  our  feeling  any  portion  of  the  cervix. 
If  the  inflammation  be  general,  that  is  what  is  felt.  But  if  the  inflam- 
mation be  unilateral  or  anterior  or  posterior  only,  the  inflammatory 
swelling  projects  in  the*  corresponding  part  only,  leaving  the  remaining 
part  of  the  circumference  of  the  cervix  accessible  to  the  finger ;  and  the 
uterus  will  be  fixed  on  the  side  of  the  swelling.  This  is  represented 
in  Fig.  99,  from  a  case  under  my  care. 


Representing  the  collar  of  hard  inflammatory  eflfusion  encircling  the  cervix  uteri. 


When  the  inflammation  is  limited  to  the  peritoneum  of  the  body  of 
the  uterus  and  the  utero-vesical  reflection — and  I  have  seen  several 
such  cases,  strictly  "  perimetritis  " — the  adhesions  contracting  in  the 
chronic  stage  pull  the  fundus  down  in  nutation ;  the  os  uteri  is  thrown 
up  and  backwards  in  the  contrary  direction,  so  that  it  is  actually  higher 
than  normal.  And  since  the  packing  of  cellular  tissue  between  the 
cervix  uteri  and  the  base  of  the  bladder  may  not  be  affected,  the  finger 
is  free  to  travel  all  round  the  vaginal-portion  in  front  as  well  as  else- 
where. But  by  pressing  a  little  firmly  in  the  anterior  vaginal  roof  we 
are  sure  to  come  upon  a  firm  resisting  plane  or  prominence,  which  is 
caused  by  the  inter-utero-vesical  consolidation. 

Fixing  or  immobilization  of  the  uterus  may  generally  be  accepted  as 
a  sign  of  peritonitis  with  adhesive  effusions.  In  the  case  of  localized 
cellulitis,  especially  in  the  utero-vesical  connection,  the  uterus  may 
move  along  with  the  phlegmonous  mass  and  the  bladder.  In  the  case 
of  retro-uterine  peritonitis,  the  tumefaction,  or  rather  tumor  formed  by 
the  effused  lymph  and  serum,  may  attain  considerable  magnitude, 
pushing  the  uterus  forward,  rising  above  the  fundus  of  this  organ,  and 


PELVIC    INFLAMMATION.  499 

coming  within  reach  of  the  fingers  applied  above  the  symphysis  pubis. 
In  not  a  few  cases,  even,  the  peritoneal  investment  of  the  opposed  in- 
testines and  omentum  being  caught,  a  large  firm  tumor  may  be  formed, 
reaching  to  the  umbilicus  and  even  higher.  This  is  especially  the 
case  when  the  peritonitis  is  caused  by  a  retro-uterine  hsematocele. 

When  the  inflammation  is  unilateral,  I  have  often  been  struck  with 
the  sensation  of  a  firm,  almost  knife-like,  or  rather  "  hog-back"  ridge, 
running  from  the  edge  of  the  os  uteri  across  to  the  side  of  the  pelvis. 
In  these  cases,  in  the  adhesive  stage,  the  fundus  uteri  is  pulled  towards 
the  affected  side. 

The  sound,  although  not  generally  necessary,  often  lends  precision 
to  the  investigation.  For  instance,  when  adhesive  inflammation  pre- 
vents the  finger  in  vagina,  or  hand  above  pnbes  from  tracing  the  form 
and  position  of  the  body  of  the  uterus,  this  being  concealed  in  a  mass 
of  firm  effusion,  we  cannot  easily  tell  whether  a  hard  rounded  mass 
projecting  the  posterior  roof  of  the  vagina  be  the  retroflected  uterus  or 
a  retro-uterine  mass  of  inflammatory  deposit.  The  sound  at  once  puts 
us  right  by  defining  exactly  the  course  of  the  uterus.  The  sound  in 
uterus  thus  serves  as  a  central  axis  from  which  we  may  estimate  the 
relations,  bulk,  and  nature  of  all  the  surrounding  structures.  It  also 
enables  us  to  test  more  closely  the  degree  of  mobility  the  uterus  enjoys. 
The  sound  being  in  the  uterus,  on  depressing  the  fundus  or  the  inflam- 
matory mass  above  the  pubes,  any  movement  imparted  is  clearly  seen 
and  felt  by  the  descent  or  obliquity  communicated  to  the  handle  of  the 
instrument.  Mobility  en  bloc  is  preserved  in  a  modified  degree  until 
the  adhesions  extend  to  the  walls  of  the  pelvis. 

When,  suppuration  having  taken  place  and  the  abscess  is  pointing 
in  the  roof  of  the  vagina,  we  may  feel  a  part  which  before  had  been 
hard,  brawny,  become  soft,  permitting  the  tip  of  the  finger  to  sink  in, 
and  immediately  to  bulge  again  as  pressure  is  taken  off.  There  is,  in 
fact,  fluctuation.  It  may  not  be  possible  to  get  a  wave  propagated  to 
the  touching  finger  by  percussion  at  another  part  of  the  sac,  but  it  is 
quite  possible  to  get  what  is  strictly  fluctuation  by  one  finger.  When 
a  liquid  is  displaced  by  pressure,  and  flows  back  on  the  removal  of  the 
pressure,  there  is  fluctuation,  and  this  wave  may  be  felt  by  delicate 
contact  preserved  upon  the  containing  sac.  The  pointing  spot,  soft  and 
prominent,  is  surrounded  by  a  hard  mass. 

When  the  abscess  points  within  the  rectum,  we  may  commonly  make 
out  the  same  conditions  by  rectal  touch. 

Rectal  toueh  furnishes  valuable  assistance.  It  checks  and  extends 
the  information  obtained  by  abdomen  and  vagina.  The  finger,  cours- 
ing along  the  anterior  wall  of  the  rectum,  can  reach  considerably  above 
the  level  of  the  os  uteri.  If  the  case  be  one  of  inter-utero-vesical  cel- 
lulitis, the  finger  can  explore  the  posterior  wall  of  the  uterus,  determine 
its  condition,  and  ascertain  if  it  be  bent  or  straight,  free  or  not  from 
tumor.  In  the  case  of  lateral  cellulitis  and  peritonitis,  the  finger  can 
commonly  feel  above  the  lower  margin  of  the  inflammatory  swelling 
projecting  into  the  vagina,  and  even  trace  it  as  a  curved  ridge  across  to 
the  sides  of  the  pelvis.     Combined  wdth  abdominal  palpation,  the  size, 


500  PELVIC    INFLAMMATION. 

position  and  relations  of  the  uterus  with  the  surrounding  inflammatory 
swellings  can  often  be  defined. 

The  finger  having  reached  the  level  of  the  os  uteri,  comes  upon  the 
hard  peri-uterine  tumefaction  ;  it  is  commonly  compelled  by  the  back- 
ward projection  of  this  tumefaction  to  be  directed  backwards  into  the 
hollow  of  the  sacrum,  following  the  globe  which  carries  the  anterior 
wall  of  the  rectum  against  the  posterior  wall.  In  this  M'ay  we  some- 
times find  the  rectum  remarkably  compressed,  and  its  calibre  contracted. 
Tracing  the  inflammatory  swelling  to  the  sides  of  the  pelvis,  we  find 
the  pelvic  structures,  those  of  the  broad  ligament  especially,  fixed  to 
the  pelvic  wall,  perhaps  on  either  side  of  the  rectum,  by  adhesive  eflii- 
sion  forming  a  collar  through  which  the  rectum  passes. 

Three  varieties  of  peritonitis  in  many  points  resemble  pelvic  peri- 
tonitis, and,  indeed,  frequently  are  associated  with  it.  One  is  perityph- 
litis ;  the  second,  a  localized  adhesive  peritonitis,  occupying  one  iliac 
fossa;  the  third,  peritonitis  of  the  lower  part  of  the  abdomen  connected 
with  cancerous  affection  of  the  pelvic  organs  and  lumbar  glands. 

In  the  case  of  perityphlitis,  the  tumor  is  always  on  the  right  side ; 
it  is  higher,  generally,  than  inflammations  springing  from  the  pelvis ; 
it  rarely  passes  beyond  the  median  line,  and  does  not  extend  into  the 
pelvic  cavity ;  and  the  greatest  bulk  or  diameter  of  the  tumor  is  above 
the  pelvis,  whereas  in  pelvic  peritonitis,  the  supra-pubic  portion  of  the 
tumor  can  be  traced  downwards  into  the  pelvic  brim,  and  by  combin- 
ing vaginal  touch  is  felt  to  be  a  part  of  inflammatory  masses  in  the 
pelvis.  The  localized  peritonitis  of  the  hypogastrium  is  also  distin- 
guished by  its  not  penetrating  the  pelvic  cavity.  And  in  both  these 
cases  the  mobility  of  the  uterus  is  commonly  preserved. 

The  cancerous  inflammation  in  many  cases  takes  its  rise  in  malignant 
disease  of  the  ovaries ;  and  especially  when  the  lumbar  glands  are  in- 
volved. In  this  case  the  disease  is  not  so  often  localized  or  encysted. 
Dropsy  of  the  peritoneum,  ascites,  not  seldom  attends.  The  signs  of 
the  cancerous  cachexia  will  rarely  be  absent.  But  at  certain  stages  of 
either  disease  vaginal  examination  may  lead  into  error.  Before  the 
ulcerative  stage  of  cancer  has  commenced,  and  therefore  before  the 
malignant  cachexia  has  become  marked,  the  uterine  neck  may  be  found 
set  fast  in  the  roof  of  the  vagina  by  surrounding  deposit,  hard  in  some 
cases  to  distinguish  from  the  deposit  of  simple  inflammation.  There 
are  features  of  differentiation.  In  malignant  disease  of  the  vaginal- 
portion,  in  the  first  place,  the  history  will  generally  be  different ;  the 
disease  has  come  on  insidiously  ;  its  early  stages  have  probably  escaped 
observation;  whilst  in  perimetric  inflammation  the  starting-point  is 
usually  labor,  abortion,  a  chill,  accident,  surgical  operation,  or  other 
well-defined  antecedent.  In  malignant  disease,  the  jierimetric  eff'usion 
is  usually  pretty  uniform,  that  is,  it  extends  all  round  the  vaginal-por- 
tion, catching  the  bladder  and  rectum;  whilst  in  inflammation  the 
deposit  is  often  unilateral  or  anterior  or  posterior,  causing  deviation  of 
the  OS  uteri  from  its  central  position,  and  permitting  the  finger  to  touch 
a  part  of  the  circumference  of  the  cervix,  and  ascertain  that  it  is  smooth. 
When  these  points  are  made  out,  the  diagnosis  of  perimetric  effusion 
is  sufficiently  decisive.     But  occasionally  cancer  is  first  noticed  shortly 


PELVIC    INFLAMMATION.  501 

after  a  labor;  and  not  seldom  inflammatory  deposits  encircle  the 
vaginal-portion  all  round.  In  these  ambiguous  conditions,  we  must 
fall  back  on  individual  tactus  eruditus ;  and  now  and  then  we  must 
suspend  our  judgment,  waiting  for  the  more  characteristic  changes 
which  time  will  certainly  bring.  That  there  is  a  difference  in  the  feel 
of  a  cancerous  os  uteri  and  its  entourage  and  that  of  inflammatory  effu- 
sion, is  certain.  The  first  is  more  nodular,  perhaps  harder,  "  stony  ;" 
the  disease,  in  short,  may  be  traced  to  the  cervix  uteri  itself,  as  its 
centre  of  departure,  whilst  this  part  is  only  engorged,  abraded  perhaps 
in  the  second  case.  But  it  is  difiicult  to  describe  the  tactile  sensations 
produced  by  degrees  of  solidity  and  shape.  Practice  alone  can  teach 
the  finger  to  recognize  them. 

A  difference  worth  remembering  is,  that  cancer  makes  a  hard  cervix, 
whilst  pelvic  cellulitis  or  peritonitis  makes  hard  masses  round  about 
the  cervix. 

The  chief  objective  characters  of  perimetric  inflammation  are  described 
with  great  accuracy  and  point  by  Doherty,  in  a  memoir/  which  consti- 
tuted an  important  chapter  in  the  history  of  the  subject.  "On  intro- 
ducing the  finger  into  the  vagina  we  find  the  hardness,  so  remarkable 
in  the  iliac  fossa,  has  extended  to  theroof  of  the  vagina,  which  is  tender 
to  the  touch,  and  as  firm  and  inelastic  as  a  deal  board — a  condition 
which  must  immediately  arrest  our  attention.  Not  the  slightest  im- 
pression can  be  made  on  it  by  our  pressure,  while  we  may  observe  that 
the  uterus  is  bound  down  to  the  affected  side,  either  throughout  its 
whole  extent,  by  which  it  suffers  a  lateral  displacement,  or  only  par- 
tially, so  that  the  fundus  is  drawn  in  one  direction,  while  the  os  tincse 
is  turned  in  the  opposite." 

An  observation  of  Aran  is  important.  He  says  small  perimetric 
inflammatory  swellings  may  have  their  seat  in  the  subperitoneal  cel- 
lular tissue;  but  the  voluminous  swellings  are  the  result  of  perimetric 
peritonitis. 

The  subject  of  diagnosis  may  be  appropriately  concluded  with  the 
caution  not  to  pursue  it  at  the  bedside  with  too  much  zeal.  By  insti- 
tuting repeated  and  minute  explorations  it  is  very  easy  to  do  a  great 
deal  of  harm  to  the  patient — more  than  enough  to  counteract  any  good 
which  the  knowledge  thus  derived  may  enable  us  to  apply.  Nothing 
in  the  treatment  is  so  necessary  as  ''  rest "  of  the  affected  parts ;  and 
examinations  mean  disturbance. 

The  treatment,  like  that  of  metritis,  must  vary  according  to  the  types 
of  the  disease  and  its  complications.  If  the  result  be  puerperal  metritis 
associated  with  septicsemia,  the  treatment  of  the  perimetric  inflammation 
is  simply  subsidiary  to  that  of  the  puerperal  fever.  In  the  more  purely 
inflammatory  cases,  whether  post-puerperal  or  not,  leeches,  to  the 
number  of  twelve  or  twenty,  to  the  groins  and  hypogastriura,  will  gen-, 
erally  be  useful  in  the  early  stage.  Fomentations  or  moist  warmth 
applied  by  a  large  thick  linseed-meal  poultice  or  spongio-piline  are  of 
material  service.     In  many  cases  to  which  I  have  been  called  in  con- 

^  "  On  Chronic  Inflammation  of  the  Uterine  Appendages  occurring  after  Partu- 
rition," 1843. 


502  PELVIC    INFLAMMATIOK. 

sultation  not  only  had  leeches  already  been  applied,  but  calomel  and 
opium  had  been  steadily  given.  It  was  manifest  to  me  that  this  treat- 
ment had  often  done  good.  This  favorable  opinion  has  been  confirmed 
by  the  observation  of  cases  so  treated  by  myself  from  the  beginning. 
A  pill  of  one  or  two  grains  of  calomel  with  half  a  grain  of  opium  may 
be  given  every  four  hours  for  twenty-four  hours ;  and  then  every  six 
or  eight  hours  for  a  day  or  two  longer.  If  there  is  any  disposition  to 
diarrhoea  the  calomel  may  be  reduced,  and  the  opium  increased.  Or, 
in  some  cases,  I  have  been  better  pleased  with  pills  or  powders  consist- 
ing of  three  grains  of  gray  powder  and  five  grains  of  Dover's  powder. 

An  obstacle  to  this  and  other  treatment,  however,  often  exists  in 
obstinate  nausea,  hiccup,  or  vomiting.  To  subdue  this  symptom  is 
the  first  necessity.  Bismuth,  hydrocyanic  acid,  creasote,  ice,  soda- 
water  in  various  combinations,  will  be  useful.  To  allay  fever,  the 
acetate  of  ammonia  and  nitrate  of  potash  with  a  sedative  answer  best. 

In  the  more  chronic  stages,  where  there  is  no  obvious  process  of 
suppuration  or  pointing,  blisters  applied  to  the  groins  and  hypogastrium 
are  often  of  great  service.  In  the  same  stage  iodide  of  potassium  be- 
comes extremely  serviceable,  and  may  be  combined  with  bark  in  decoc- 
tion or  tincture. 

The  question  as  to  opening  abscesses  does  not  seem  to  demand  much 
discussion.  Not  seldom  Nature  solves  it  for  herself.  The  abscess 
bursts  into  the  rectum  or  roof  of  the  vagina  without  obvious  warning ; 
and  generally  recovery  progresses  from  that  event.  It  seems  to  me 
that  these  are  the  easiest  routes ;  that  evacuation  by  them  takes  place 
earlier,  and  often  with  less  disturbance.  This  may  be  partly  because 
the  walls  of  these  organs  are  thinner  and  more  easily  perforated  than 
the  abdominal  wall.  At  any  rate  the  pointing  and  perforation  of  the 
abdominal  wall  is  often  slow  and  painful.  The  progress  of  an  abscess 
towards  the  skin  generally  makes  itself  visible  by  the  growing  promi- 
nence and  puffiness  of  the  tumor,  its  reddening,  its  fliuctuation,  and 
finally  by  the  skin  becoming  blue  and  palpably  thin.  It  is  possible 
to  err  by  opening  an  abscess  too  soon  and  too  late.  If  an  inflammatory 
tumefaction  be  opened  before  fluctuation  is  made  out  we  may  fail  to 
find  pus ;  the  incision  must  be  carried  deeply  through  tender  vascular 
structures,  and  cause  serious  bleeding;  and  the  suppuration-process 
will  not  be  stopped.  On  the  other  hand,  if  we  wait  until  the  abscess 
is  on  the  verge  of  bursting  we  shall  have  prolonged  unnecessarily  the 
patient's  suffering;  the  blue  skin  may  slough  in  spite  of  puncture,  and 
will  only  heal  with  an  ugly  scar ;  and  there  is  the  risk  of  the  abscess 
effecting  an  opening  internally  into  the  peritoneum  or  in  some  other 
direction  as  well.  The  proper  time  for  opening  an  abscess  pointing  to 
the  skin  appears  to  me  to  be  as  soon  as  fluctuation  is  clearly  ascertained. 
Incision  may  be  made  with  a  bistoury,  or  a  Syme's  knife ;  and  if  a 
depending  position  cannot  be  obtained  a  drainage-tube  will  be  useful. 
The  wound  should  not  be  allowed  to  close  at  once,  as  pus  will  continue 
to  flow  for  two  or  three  days  at  least.  To  keep  it  open  a  strip  of  lint, 
soaked  in  carbolic  oil,  may  be  inserted  into  the  wound.  I  think  it  is 
important  to  keep  the  cavity  of  the  sac  as  small  as  possible,  by  adjust- 
ing compresses  in  such  a  manner  as  to  bring  the  walls  together. 


PELYIC    HEMATOCELE.  503 

If  we  find  fluctuation  in  the  roof  of  the  vagina  or  in  the  rectum  the 
same  rule  should  be  followed.  The  puncture  may  be  made  by  a  long 
sharp-pointed  hernia  knife,  or  by  a  long  trocar — for  the  rectum  the 
long  curved  trocar  used  for  tapping  the  male  urethra  is  very  conveni- 
ent. Where  there  is  any  doubt  as  to  the  presence  of  pus  the  fine  aspi- 
rator-trocar is  the  proper  instrument  to  use.  It  is  sometimes  an  ad- 
vantage to  insert  a  drainage-tube  in  the  case  of  opening  an  abscess  by 
the  vagina.  An  excellent  and  convenient  drainage-tube  will  be  found 
in  the  Avinged  male  catheter.  It  is  easily  inserted,  by  passing  the 
stilet  into  the  eyelet  near  the  end.  Thus  supported  it  is  carried  into 
the  sac,  where  the  end  is  retained  by  the  wings.  Whether  the  opening 
be  effected  spontaneously  or  artificially,  by  the  rectum  or  the  vagina,  it 
is  desirable  to  apply  moderate  pressure  to  the  upper  part  of  the  tumor 
by  pads  and  bandage  to  the  abdomen. 

When  an  abscess  has  been  opened,  and  sometimes  earlier,  quinine 
generally  becomes  useful.  The  diet  should  be  nutritious  and  support- 
ing.    Rest  will  still  be  necessary. 

At  a  later  period,  when  suppuration  has  ceased,  quinine  may  still 
be  useful ;  but  iron  now  comes  into  service.  The  bowels  must  be  kept 
gently  acting.  Bed  may  be  changed  in  the  daytime  for  the  sofa;  and 
gradually,  but  watchfull}^,  gentle  exercise  may  be  indulged  in.  If 
taken  too  soon,  or  exceeding  moderation,  it  is  always  probable,  so  long 
as  any  marked  intumescence  or  diminished  mobility  of  the  uterus  re- 
main, that  a  return  of  inflammation  may  occur. 

In  the  advanced,  or  confirmed  chronic  cases,  warm  baths  will  render 
great  service.  The  iron-waters  are  not  always  safe.  I  believe  many 
experienced  physicians  have  arrived  at  this  conclusion.  The  best  re- 
sults I  have  seen  have  been  derived  from  the  Woodhall  Spa. 


CHAPTER  XLII. 

PERIMETRIC  HEMATOCELE;  RETRO-UTERINE  HEMATOCELE; 
PELVIC  HEMATOCELE;  BLOOD-EFEUSIONS  IN  THE  NEIGH- 
BORHOOD OF  THE  UTERUS. 

The  study  of  perimetric  hoBmatocele  most  conveniently  follows  im- 
mediately upon  that  of  perimetric  inflammation.  Clinically,  the  two 
conditions  have  close  relations.  Indeed,  blood-effusions  into  the  peri- 
toneum almost  necessarily  entail  pelvic  peritonitis.  And  at  the  bed- 
side the  practical  difiiculty  often  is  to  distinguish  hsematocele  from  in- 


504  PELVIC    HJEMATOCELE. 

flammatory  effusions.  It  is  certain  that  until  within  the  last  twenty 
years,  or  less,  almost  every  case  of  perimetric  hsematocele  was  con- 
founded with  inflammatory  effusions.  It  can  hardly  be  said  that 
hfematocele  had  been  recognized  as  a  distinct  affection.  And  even  now 
many  men  are  slow  to  admit  the  evidence  upon  which  its  existence  is 
established,  and  are  consequently  unable  to  appreciate  the  frequency 
or  the  conditions  of  its  occurrence. 

In  1850  only  the  disease  was  so  little  known  that  Malgaigne  is  re- 
ported to  have  attempted  the  enucleation  of  a  supposed  fibroid  tumor 
of  the  uterus,  which  proved  to  be  a  collection  of  blood;  and  the 
operation  was  followed  by  a  fatal  issue.  And  Scanzoni  says,  in  his 
work  on  "Chronic  Metritis,"  published  in  1863:  "We  regret  not  to 
be  in  a  position  from  personal  experience  to  speak  of  this  disease,  for 
in  our  certainly  extensive  and  protracted  observation  we  have  not  been 
able  to  diagnose  peri-uterine  hsematocele  in  a  single  case." 

So  long  ago,  however,  as  1831,  Recamier  described  in  the  "  Lancette 
Francaise,"  under  the  name  of  "  Turaeur  sanguine  du  bassin,"  a  very 
clear  case.  A  woman,  aged  twenty-eight,  after  an  abortion,  had  a 
large  tumor  formed  in  the  pelvis,  behind  the  uterus,  which  bulged  the 
vagina  forwards.  R^camier,  believing  it  to  be  an  abscess,  opened  it, 
but  instead  of  pus,  dark,  half-coagulated  blood  escaped.  The  patient 
recovered. 

Velpeau,  in  his  "  Medecine  Op^ratoire,"  1839,  published  additional 
cases.  He  was  evidently  acquainted  with  the  characteristic  features  of 
these  pelvic  blood-swellings. 

In  1850  and  1851  Nelaton,  in  lectures  in  the  "Gazette  des  Hopi- 
taux,"  laid  the  foundations  of  the  present  more  accurate  knowledge  of 
the  subject.  It  was  he  who  proposed  the  name  "  retro-uterine  haema- 
tocele."  From  this  date  cases  and  memoirs,  still  chiefly  emanating 
from  the  French  school,  rapidly  multiplied ;  proving  that  it  was  only 
necessary  to  look  for  examples  of  this  hitherto  unknown  affection  with 
intelligence,  in  order  to  find  them.  Vigues,  Fenerly,  Aran,  Prost, 
Bernutz,  Puech,  Nonat,  Laborderie,  Laugier,  Yoisin,  Gallard,  Richet, 
Goupil,  and  Trousseau,  have  all  contributed  important  materials. 

In  England  Tilt  and  West  were  the  first  to  describe  the  affection. 
McClintock  has  given  the  best  original  account  in  the  English  lan- 
guage.^ He  had  published  a  case  in  the  "  Dublin  Hospital  Gazette  " 
in  1860.  In  1861  Dr.  Madge  communicated  to  the  Obstetrical  Society 
a  veiy  complete  report  of  a  case,  illustrated  l)y  figures,  representing 
the  conditions  found  on  dissection,  and  commented  by  a  valuable  re- 
view of  the  subject.  Dr.  Tuckwell,  in  1863,  published  an  important 
memoir,  entitled  "  On  Effusions  of  Blood  in  the  Neighborhood  of  the 
Uterus."  This  contains  an  excellent  historical  sketch,  a  tabular  view 
of  ninety-eight  cases  collected  from  various  sources,  and  histories  of 
some  original  cases  not  before  published. 

In  Germany  contributions  have  been  accumulating  since  1859.  C. 
R.  Braun,  Alfred  Hegar,  Sjixinger,  Seyfert,  Olshausen,  and  others 
have  added  materially  to  the  casuistical  history  of  the  subject. 


1  "Diseases  of  Women,"  1863. 


PELVIC    HJEMATOCELE.  505 

Bernutz  claims  to  have  been  the  first  to  demonstrate  by  post-mortem 
examination  the  position  and  relation  that  these  tumors  hold  to  the 
uterus.  He  was  the  first  to  maintain  that  many  cases  directly  de- 
pended upon  retention  of  menstrual  blood. 

The  Seat  of  the  Blood-tumor. — The  term  "  perimetric  hfematocele  "  is 
used  to  define  the  state  of  tumor  formed  by  effusion  of  blood  in  the 
neighborhood  of  the  uterus.  It  is  more  comprehensiye  than  "  retro- 
uterine hsematocele,"  which  strictly  means  a  blood-tumor  behind  the 
uterus.  This  latter  term  is  correct  as  far  as  it  goes.  It  would  be  al- 
together correct  if  it  expressed  the  whole  truth  ;  that  is,  if  blood-effu- 
sions were  not  liable  to  occur  elsewhere  than  behind  the  uterus.  But 
blood-effusions  do  occur  in  other  relations  to  the  uterus.  To  admit 
these  into  a  general  definition  we  want  the  term  perimetric  or  peri- 
uterine hsematocele ;  or  perhaps  the  term  "  pelvic  hBematocele,"  pro- 
posed by  Dr.  McClintock,  being  more  comprehensive,  is  better  still. 

If  we  start  from  the  arbitrary  definition  which  some  have  proposed, 
namely,  to  restrict  the  term  hsematocele  to  blood-effusions  into  the 
peritoneal  cavity,  it  would  almost  necessarily  follow  that  the  adjective, 
retro-uterine,  is  the  proper  and  only  one  to  employ.  For,  if  blood  be 
poured  out  into  the  peritoneal  cavity  in  the  neighborhood  of  the  pelvis, 
it  must  gravitate  to  the  retro-uterine  pouch,  which  is  the  lowest  part 
of  the  general  cavity.  The  ante-uterine  or  utero-vesical  pouch  is  so 
shallow,  and  is  so  liable  to  disturbance  or  obliteration,  by  the  filling 
and  rising  of  the  bladder,  that  lodgment  of  fluid  blood  in  this  position 
is  rarely  possible.  If  a  little  blood  were  to  find  its  way  into  this 
pouch  it  would  probably  soon  be  dislodged,  and  made  to  run  over  the 
fundus  of  the  uterus  and  the  upper  edge  of  the  broad  ligaments  into 
the  pouch  behind.  Moreover,  the  most  frequent  sources  of  effused 
blood  are  the  ovary  and  the  extremity  of  the  Fallopian  tubes,  and 
these  parts  being  in  the  posterior  wing  of  the  broad  ligament,  blood 
from  them  naturally  falls  direct  into  the  posterior  pouch.  Intra-peri- 
toneal  effusions  then  are  almost  always  retro-uterine. 

But  is  this  all  we  have  to  consider  ?  Are  there  no  other  blood-effu- 
sions ?  Adhering  to  the  cardinal  principle  of  this  work,  that  of  making 
scientific  pathology  subsidiary  to  clinical  book,  I  have  determined  to 
bring  together  all  the  blood-effusions  Avhich  may  take  place  in  the 
neighborhood  of  the  uterus ;  and  then  to  proceed  to  analyze  or  differ- 
entiate them  as  best  we  can  by  the  aid  of  the  history  and  symptoms  of 
individual  cases  and  of  general  experience  and  pathological  knowledge. 
It  is  only  in  this  way  that  we  can  usefully  investigate  any  given  case. 
We  may  not  know,  in  the  first  instance,  what  the  source  of  the  bleeding 
may  be,  or  the  particular  nature  of  the  lesion  which  led  to  it.  That 
is  a  problem  to  be  solved  by  clinical  investigation.  In  a  memoir  on 
this  subject'  I  distributed  in  groups  all  the  cases  I  had  met  with  which 
were  characterized  by  the  escape  of  blood  in  considerable  quantity  into 
the  pelvic  peritoneum.  Some  of  these  groups  included  cases  which 
those  who  look  at  the  subject  from  a  rigorous  systematic  point  of  view 
refuse  to  recognize  as  legitimate  examples  of  retro-uterine  hsematocele. 

1  St.  Thomas's  Hospital  Reports. 


506  PELVIC    HEMATOCELE. 

But  the  objection,  I  submit,  is  critical,  not  practical.  It  seems  unrea- 
sonable to  contend  that  a  case  of  rupture  of  the  uterus,  or  of  an  extra- 
uterine gestation-sac,  one  of  the  almost  certain  effects  of  which  is  effu- 
sion of  blood  into  the  peritoneum,  is  not  a  case  of  retro-uterine  hsema- 
tocele.  It  is  quite  arbitrary  to  restrict  the  term  to  effusions  of  blood 
the  result  of  one  particular  cause ;  for  example,  rupture  of  ovarian  ves- 
sels. In  no  case  is  the  outpoured  blood  the  disease.  It  is  only  a  con- 
sequence of  some  lesion  or  injury.  In  some  cases  the  more  immedi- 
ately serious  symptoms  are  due  to  the  shock  of  the  injury ;  in  others, 
to  the  loss  of  blood  and  the  attendant  shock.  This  difference  is  an 
accident,  of  clinical  importance,  it  is  true,  but  still  not  such  a  difference 
as  to  dictate  absolute  separation  of  the  cases  possessing  so  important  a 
common  feature  as  hemorrhage. 

In  all  the  cases  the  hemorrhage,  sooner  or  later,  is  a  serious  element. 
In  all  hemorrhage  plays  an  important  part.  First,  by  the  shock  caused 
by  the  sudden  impression  of  the  outpoured  blood  upon  the  peritoneum; 
secondly,  by  the  loss  of  blood ;  thirdly,  by  the  consequent  peritonitis. 
The  patient  may  be  destroyed  by  the  shock  alone,  or  by  the  shock 
combined  with  the  loss  of  blood,  before  there  is  time  for  inflammation 
to  arise.  This  is  to  say,  that  in  those  most  formidable  cases,  as  of 
rupture  of  the  uterus,  or  of  an  extra-uterine  gestation-sac,  life  may  be 
extinguished  before  a  hsematocele,  properly  speaking,  is  formed.  But 
this  is  no  more  than  is  true  of  those  usually  less  fulminating  cases,  in 
which  the  blood  proceeds  from  burst  ovarian  vessels.  In  these  cases 
sometimes  the  shock  and  bleeding  kill  before  a  tumor  can  be  formed 
by  the  segregation  of  the  blood  by  inflammatory  effusions.  In  all 
there  are  common  features  which  bind  them  together  as  members  of 
one  clinical  family. 

Putting  aside  then  for  the  present  all  pathogenic  theories,  we  shall 
find  that  the  cases  of  perimetric  hemorrhage  may  be  arranged  as 
follows : 

f     T     M  *.  J      fl-  Rupture  of  uterus. 


T     M  *.  J      fl-  Rupture  of  uterus. 

I.  Non-encysted     I  ^         \,         of  tubal-cyst. 
(cataclysmic).  I  3_         ,         of  ovary. 


Intra-peritoneal  ^          „         of  subovarian  vessels, 
(retro-uterine). 

I  II.  Encysted  (peri- /  1.  Menstrual. 

I  tonitic).           1 2.  Abortion, 

-p                .           ,   /  I.  In  the  broad  ligaments. 

iliXtra-pentoneai.  ^  jj-_  -j-^  cellular  tissue  between  cervix  uteri  and  bladder. 
III.  In  cellular  tissue  between  uterus  and  rectum. 


I  do  not  pretend  that  this  is  a  rigorously  exact  classification.  Hem- 
orrhage from  rupture  of  an  extra-uterine  gestation-sac  may  become 
encysted ;  hemorrhage  from  menstrual  deviation  may  be  cataclysmic. 
But  if  we  regard  the  arrangement  simply  as  a  framework  for  descrip- 
tion, it  will  be  found  useful  in  aiding  to  obtain  a  clear  knowledge  of 
the  subject. 

When  blood  is  rapidly  poured  out  in  large  quantities  into  the  peri- 
toneal cavity  the  shock  and  loss  of  blood  alone,  as  we  have  seen,  may 
kill.     No  opportunity  is  given  for  the  establishment  of  the  conserva- 


PELVIC    HEMATOCELE.  507 

tive  process  of  inflammation,  which,  by  segregating  the  blood  in  one 
mass  in  one  compartment  of  the  peritoneum,  limits  both  the  quantity 
of  blood  effused  and  the  area  of  irritation,  and  hence  the  extent  of 
shock.  In  such  a  case  the  hemorrhage  is  said  to  be  "  non-encysted." 
Looking  at  the  terrible  suddenness  and  severity  of  the  blow  struck  at 
the  vital  powers,  I  have  called  these  cases  "  cataclysmic." 

The  most  common  causes  of  the  effusion  in  these  non-encysted  or 
cataclysmic  cases  are  rupture  of  the  uterus,  gravid  or  not  gravid, 
rupture  of  a  tubal  gestation-cyst,  rupture  of  a  diseased  ovary,  or  of  a 
varix  of  the  pampiniform  plexus. 

But  in  some  cases  where  the  hemorrhage  is  due  to  one  of  these 
causes  the  blood  does  become  encysted.  The  course  they  run  resem- 
bles closely  that  run  by  the  cases  of  the  second  order,  in  which  the 
source  of  the  blood  is  the  gorged  vessels  of  the  ovary,  or  the  Fallopian 
tubes  during  menstruation  or  abortion.  And  even  in  some  of  these 
latter  cases  the  blood  is  poured  out  so  rapidly  that  it  does  not  become 
encysted.     These  too  may  be  cataclysmic. 

Instances  of  encysted  hsematocele  resulting  from  ruptured  extra- 
uterine gestation-sacs  are  reported  by  Voisin,  Aran,  and  myself,  and 
many  others. 

Nor  can  the  extra-peritoneal  cases  be  on  sound  clinical  or  patholog- 
ical grounds  separated  from  the  intra-peritoneal  cases.  If  we  base  our 
classification  or  definition  on  origin,  we  shall  find  that  some  of  the 
same  causes  which  lead  to  blood-effusions  into  the  peritoneum  may  lead 
to  blood-effusions  outside  the  peritoneum  into  the  perimetric  cellular 
tissue.  And  more  than  this,  we  shall  find  cases  in  which  the  blood 
being  first  effused  into  the  cellular  tissue  has  burst  its  way  through  the 
peritoneum  into  the  peritoneal  cavity ;  thus  breaking  down  the  arbi- 
trary barrier  which  theory  had  placed  between  the  two  orders  of  cases. 

We  see  then  from  this  statement  that  the  perimetric  blood-effusions 
are  brought  into  close  pathological  and  clinical  relationship  with  the 
so-called  "  thrombus,"  or  blood-effusion  in  the  peri-uterine  cellular 
tissue.  It  is  this  relationship  which  justifies  the  term  "  Pelvic  Hsema- 
tocele,"  proposed  by  Dr.  McClintock.  It  is  true  some  authors  of  de- 
served repute  would  exclude  all  but  intra-peritoneal  effusions.  The 
objection  to  ranking  extra-peritoneal  effusions  along  with  intra-peri- 
toneal effusions  has  been  insisted  upon  by  Voisin  and  Bernutz.  The 
latter  author,  justly  celebrated  for  the  precision  of  his  researches,  con- 
tends that  the  extra-peritoneal  effusions  are  thrombi,  and  only  result 
from  labor.  But  the  objection  of  Aran  is  more  pointed,  as  being  based 
on  a  clinical  distinction.  This  excellent  author  affirms  that  there  are 
no  subperitoneal  perimetric  blood-tumors  at  all  important  in  size,  so 
as  to  come  into  consideration.  They  cannot  become  large  because  they 
are  limited  within  the  cellulo-fibrous  layer  covered  in  by  the  perito- 
neum. To  this  it  may  be  answered  that  intra-peritoneal  retro-uterine 
effusions  are  not  always  very  large  ;  and  that  small  tumors  of  this  de- 
scription may  be  equalled  in  size  by  some  extra-peritoneal  ones.  And 
Huguier,  ISTonat,  Robert,  Becquerel,  Verneuil,  Frost,  all  maintain  that 
hsematocele  may  be  extra-peritoneal.  In  some  extra-peritoneal  cases, 
Nonat  says,  the  tumor  is  nearer  the  anus.     Frost  relates  two  well- 


508  PELVIC    HEMATOCELE. 

authenticated  cases,  in  one  of  which  the  blood  was  effused  between  the 
layers  of  the  broad  ligament,  and  in  the  other  it  occupied  the  connec- 
tive tissue  behind  the  uterus.  Tuckwell  cites  Becquerel  as  relating  a 
case  in  which  more  than  two  pounds  of  blood  were  found  outside  the 
peritoneum,  the  blood  having  dissected  its  way  between  the  different 
organs,  and  displaced  them  all.  A  specimen,  presently  to  be  described, 
in  Bartholomew's  Museum,  seems  a  clear  example  of  large  extra-peri- 
toneal heematocele. 

If  we  look  to  the  source  of  some  intra-peritoneal  effusions,  we  can- 
not fail  to  see  that  the  effusion  into  the  peritoneum  is  accidental,  that 
the  blood  would  be  quite  as  likely  to  make  for  itself  a  sac  in  the  cellu- 
lar tissue  of  the  broad  ligaments.  For  example,  a  varix,  or  the  di- 
lated pampiniform  plexus  may  be  supposed  to  give  way  without  ruptur- 
ing the  peritoneum,  the  blood  finding  a  lodgment  by  separating  the 
peritoneal  investments  of  the  broad  ligament. 

Olshausen  (Arch,  fur  Gynakol.,  1870)  relates  a  case  of  subperito- 
neal ante-uterine  catamenial  hsematocele  following  on  acute  dysmeuor- 
rhoea.  Fever,  absorption,  and  recovery  ensued.  The  anterior  lip  of 
the  OS  uteri  was  short,  whilst  the  anterior  vaginal  roof  was  driven 
backwards  by  a  tumor  of  half-soft  consistence. 

I  have  seen  two  cases  which  I  believed  were  examples  of  ante- 
uterine  hsematocele,  probably  extra-peritoneal,  since  they  corresponded 
in  relations  to  the  thrombus  which  forms  in  front  of  the  uterine  neck 
during  labor.  Both  cases  came  under  my  observation  in  the  chronic 
stage ;  in  both  there  was  a  firm  tumor,  the  size  of  a  small  orange,  in 
front  of  the  uterus,  throwing  the  fundus  uteri  backwards.  The  diag- 
nosis was  confirmed  by  the  gradual  complete  disappearance  of  the 
tumor,  without  any  signs  of  ruj)ture  or  suppuration.  These  cases  meet 
the  objection  of  Aran  that  extra-peritoneal  blood-tumors  cannot  be 
large  enough  to  enter  into  clinical  consideration.  Professor  G.  Braun 
relates  (Wien.  Med.  Wochenschr,  1872)  a  case — he  thinks  the  only 
one — in  which  ante-uterine  intra-peritoneal  hsematocele  was  diagnosed 
during  life.  A  married  woman,  aged  thirty-five,  had  a  smooth  elastic 
swelling  in  front  of  the  uterus.  Dieulafoy's  trocar  gave  issue  to  a  pint 
of  dark-red  blood.  Collapse  and  death  followed.  A  sac,  the  size  of 
a  foetal  head,  was  found  in  the  left  side  of  the  pelvis,  in  front  of  the 
uterus.     There  was  also  peritonitis. 

TuclvAvell  found  in  the  synopsis  of  cases  made  by  him  that  the  blood 
was  found  to  be  intra-peritoneal  in  thirty-eight  out  of  forty-one  post- 
mortem examinations ;  that  in  twenty-six  of  the  thirty-eight  it  was 
diffused,  and  in  twelve  circumscribed,  and  limited  to  the  retro-uterine 
cul-de-sac. 

We  are  then  drawn  to  the  conclusion  that  there  are  cases  of  both 
kinds ;  but  that  the  intra-peritoneal  blood-effusions  are  by  far  the  most 
common,  apart  at  any  rate  from  pregnancy  and  labor. 

Perimetric  hemorrhage  may  occur  in  the  pregnant  state  and  in  the 
non-pregnant  state ;  and  in  either  case  the  effusion  may  be  intra-peri- 
toneal or  extra-peritoneal.  It  does  not  fall  within  the  scope  of  this 
work  to  describe  the  accidents  of  the  pregnant  state.  But  some  of  the 
conditions  of  uterine  pregnancy,  and  more  especially  those  of  abnormal 


PELVIC    HEMATOCELE.  509 

pregnancy,  are  so  connected  with  the  history  and  diagnosis  of  perimetric 
hsematocele  that  no  complete  idea  can  be  formed  of  the  subject,  if  we 
exchide  the  blood-effusions  of  pregnancy  from  the  discussion.  An  all- 
sufficient  reason  for  taking  these  into  account  is  that  in  many  instances 
we  cannot  know  at  the  time  of  the  accident  what  the  source  of  the  hem- 
orrhage is,  or  whether  the  subject  is  pregnant  or  not. 

The  'pathology  of  intra-peritoneal  hsematocele  is  well  illustrated  in 
the  following  cases.  Olshausen  relates^  the  case  of  a  woman,  aged 
twenty-five,  who  was  delivered  in  March,  1863,  of  her  first  child. 
Menstruation  returned  regularly  until  the  middle  of  September.  In 
the  middle  of  October  it  returned  too  early,  and  with  repeated  pain  in 
the  belly,  and  vomiting.  Thenceforward  metrorrhagia  lasted  for  seven 
weeks.  She  walked  into  the  physician's  room.  There  was  frequent 
desire  to  micturate.  In  the  median  line  of  the  abdomen  was  a  ball- 
shaped,  somewhat  painful  tumor,  the  size  of  a  gravid  uterus  at  three 
months.  The  os  uteri  was  driven  against  the  symphysis  pubis ;  behind 
it  was  a  ball-shaped,  slightly  painful  elastic  swelling,  filling  the  hollow 
of  the  sacrum.  The  tumor  became  less  in  bulk,  and  harder.  She  died 
in  June,  1864,  of  typhus.  At  the  autopsy  adhesions  were  found  in 
Douglas's  space,  especially  behind  the  broad  ligaments.  A  membrane 
extended  from  the  point  of  insertion  of  the  left  broad  ligament  to  the 
cervix  uteri  backwards  to  the  rectum,  dividing  off  a  small  portion  of 
the  retro-uterine  pouch  ;  in  this  a  small  coagulura  remained,  containing 
fluid  in  its  centre.  It  lay  quite  free.  The  space  showed  a  remarkable 
pigmentation  abruptly  terminating  above,  yellow  and  black  in  the  tis- 
sue of  the  peritoneum.     Both  ovaries  adhered  to  the  uterus. 

The  anatomical  illustrations  in  the  London  museums  are  few. 
Amongst  the  most  striking  is  one  in  St.  Thomas's,  a  representation  of 
which  is  given  in  Fig.  101,  p.  515. 

There  is  a  very  interesting  specimen  in  Guy's  Museum  (Fig.  100). 
It  is  not  described  in  the  catalogue.  It  shows  the  remains  of  a  blood- 
cyst,  h,  h,  behind  the  uterus  in  Douglas's  pouch.  The  peritoneal  sur- 
face is  roughened  by  inflammatory  deposits  tinged  with  blood -debris. 

There  is  a  specimen  in  Bartholomew's  Museum  of  sj^ecial  interest 
(No.  31.36)  thus  described  : 

"  Uterus  and  appendages.  Between  the  layers  of  the  right  broad  liga- 
ment is  a  globular  cyst,  about  as  big  as  a  walnut,  whose  walls  in  the 
recent  state  were  seen  to  be  formed  by  the  separated  layers  of  the  liga- 
ment, and  whose  cavity  was  filled  with  quite  recent  blood-coagula.  On 
the  anterior  aspect  of  the  cyst  were  two  small,  recently  formed  irregular 
openings. 

"  From  a  patient,  aged  twenty-five,  who,  while  in  the  hospital  for 
treatment  of  warts  on  the  vulva,  was  suddenly  attacked  with  symptoms 
of  internal  hemorrhage,  and  died  in  twelve  hours.  Post  mortem  :  The 
cavity  of  the  peritoneum  contained  five  pints  of  recently  shed  blood, 
loosely  coagulated ;  and  dark  fluid  blood  oozed  slowly  from  the  open- 
ings in  the  cyst  above  described.  The  interior  of  the  uterus,  along 
with  all  the  other  parts  of  the  body,  was  very  pale.     Careful  examina- 

1  Archiv  fiir  Gynakologie,  1870. 


510 


PELVIC    HEMATOCELE. 


tion  failed  to  discover  the  source  of  the  hemorrhage.  No  evidence  of 
extra-uterine  pregnancy,  no  ruptured  vessel  was  discovered.  It  is 
uncertain  whether  the  patient  was  menstruating  at  the  time  of  the 
attack." 

Fig.  100. 


tv-^ 


(From  Guy's  Museum,  half-size.) 
Remains  of  a  retro-uterine  hoematocele. 

o.  The  right  ovary  laid  open,    h,  h.  The  roughened  peritoneum  of  Douglas's  pouch,  which  formed  the 
anterior  wall  of  the  sac  of  the  hsematocele. 


The  nature  of  the  cyst  in  the  broad  ligament  is  not  clear.  Was  it  a 
simple  cyst,  such  as  is  not  uufrequently  seen  in  this  situation  ?  If  so, 
how  can  we  account  for  its  becoming  filled  with  blood  ?  Is  it  a  true 
extra-peritoneal  hsematocele,  resulting  from  rupture  of  a  vessel  in  the 
broad  ligament,  the  sac  subsequently  bursting,  and  giving  rise  to  a  cata- 
clysmic intra-peritoneal  eifusion  ?  This  seems  to  be  the  more  probable 
conjecture.  At  any  rate,  the  specimen  gives  anatomical  demonstration 
of  the  possible  existence  of  extra-peritoneal  hsematocele. 

The  following  case  from  Olshausen  affords  distinct  evidence  of  the 
genesis  and  nature  of  the  affection.  Atresia  of  the  vagina  after  typhus ; 
hsematometra  and  hsematocele ;  death  by  peritonitis ;  regurgitatiou  of 
blood  through  the  tubes.  When  the  subject  came  under  treatment 
fluctuation  was  felt  by  rectum.  Puncture  made  by  rectum  let  out  a 
little  thick  blood.  Two  days  later  at  stool  a  larger  quantity  was  voided. 
Peritonitis  and  death  quickly  followed.  On  dissection  diffuse  perito- 
nitis, with  copious  purulent  exudation,  was  found.  Blood-remains 
were  seen  in  Douglas's  pouch.  The  uterus  was  much  enlarged ;  its 
cavity  empty.  Both  tubes  were  much  dilated,  darkly  pigmented  in- 
side, chiefly  towards  the  uterine  ends.  Both  ostia  uterina  allowed  a 
sound  to  pass  easily.  The  left  ovary  contained  several  small  cavities 
filled  with  blood ;  it  adhered  to  the  uterus. 

Dr.  Jilno-el  told  Dr.  Ferber  that  in  about  3000  minute  dissections 


PELVIC    HEMATOCELE.  511 

of  women  he  had  never  found  hsematocele  or  remains.  On  the  other 
hand,  obvious  remains  of  pelvi-peritonitis,  and  of  slight  pigmentation 
of  Douglas's  pouch  were  very  frequent.  In  pueUis  publicis  pelvi-peri- 
tonitis of  old  or  recent  date  was  always  found,  but  never  hfematocele. 

Since  pigmentation  is  probably  the  residuum  of  blood,  the  presump- 
tion is  that  small  hsematoceles  are  not  unfrequent.  It  is  certain  that 
adhesions  often  disappear  so  as  to  leave  scarcely  a  trace  behind. 

Heurtaux  describes  the  following  confe?ife  of  a  hcematocele :  1.  Drop- 
lets like  oil  of  a  brown-yellow  color ;  2.  Spherical  cells,  entire  or  re- 
duced to  fragments,  abounding  in  adipose  nucleoli ;  3.  Amorphous 
fragments  of  hsematoidin  ;  4.  Quad rilated  crystals,  resembling  ammo- 
nio-magnesian  phosphates ;  5.  Some  blood-globules,  well  colored ;  6. 
An  extraordinary  quantity  of  blackish  corpuscles,  of  various  forms, 
resulting  from  the  alteration  of  the  coloring  matter  of  blood.  Dr. 
Madge  describes  the  contents  in  his  case  as  consisting  of  blood-corpus- 
cles, some  perfect,  others  undergoing  various  degrees  of  change ;  also 
pus-globules  and  little  black  and  yellow  masses,  some  of  them  assum- 
ing a  crystalline  form ;  the  chief  part,  however,  was  made  up  of  unde- 
finable  debris  of  blood,  fibrin,  and  pus. 

The  Sources  of  the  Blood-effusions. — The  seat  of  the  blood-efPusion 
being  not  constant,  it  almost  necessarily  follows  that  the  source  is  not 
constant.  I  propose  to  enumerate  the  various  sources  to  which  the 
hemorrhage  has  been  traced.  This  review  will  throw  considerable 
light  upon  the  subject.  In  the  first  place,  we  may  state  generally  that 
blood  may  be  poured  out  from  the  ovaries,  the  Fallopian  tubes,  the 
uterus,  and  from  the  broad  ligaments ;  in  the  second  place,  it  may  pro- 
ceed from  an  extra-uterine  gestation-sac,  ovarian,  tubal,  or  abdominal ; 
in  the  third  place,  it  may  proceed  from  lesion  of  some  abdominal  struc- 
ture, as  aneurism  of  the  aorta,  or  of  the  mesenteric  arteries. 

Group  I. — In  ordinary  uterine  pregnancy  the  uterus  may  rupture  at 
any  time.  H.  Cooper^  relates  a  case  of  rupture  of  the  gravid  womb  in 
the  third  month.  At  subsequent  periods  rupture  becomes  progressively 
more  frequent.  In  almost  all,  if  not  in  all,  cases  of  rupture  during 
pregnancy,  the  rent  is  through  the  body  of  the  uterus ;  and  therefore 
the  blood  escapes  into  the  peritoneal  cavity,  the  ovum  or  embryo  being 
either  retained  in  the  uterus  or  expelled  into  the  peritoneum.  In  the 
first  case,  there  is  strictly  intra-peritoneal  hemorrhage.  In  the  second, 
there  is  intra-peritoneal  hemorrhage,  complicated  with  the  presence  of 
the  embryo  and  ovum.  In  either  case  the  blood  may  or  may  not  coagu- 
late, and  become  encysted.  The  more  likely  event  is  that  it  will  not 
become  encysted,  but  that  the  patient  will  die  of  the  shock. 

The  blood  rarely  coagulates  more  than  partially ;  remaining  liquid, 
it  is  diifused  over  the  intestines,  only  a  portion  being  able  to  settle  in 
the  pelvic  cavity ;  the  conservative  peritonitis  which  under  more  favor- 
able circumstances  secludes  the  blood  in  the  pelvic  region  by  plastic 
effusions  cannot  take  place.  It  does  not,  in  technical  language,  become 
"  encysted."  It  therefore  does  not  form  a  tumor :  it  is  not  a  "hsemato- 
cele."    It  is  the  most  severe  form  of  intra-peritoneal  hemorrhage,  re- 


'  British  Medical  Journal,  1850. 


512  PELVIC    HEMATOCELE. 

sembling  the  bursting  of  an  aneurism.  It  is  a  cataclysm  of  blood,  not 
a  slow  or  gradual  effusion.  In  this  respect,  but  differing  in  some  of  its 
symptoms,  cases  of  rupture  of  the  gravid  uterus  resemble  those  in  the 
next  group,  in  which  the  cyst  of  an  extra-uterine  gestation  bursts. 

Group  II. — In  abnormal  or  ectopic  pregnancy,  rupture  of  the  fruit- 
sac  is  a  still  more  frequent  issue;  and  this  at  so  early  a  period  that  the 
existence  of  pregnancy  may  be  unsuspected  or  doubtful.  This  subject 
has  been  treated  of  in  some  detail  in  a  special  chapter.  It  is  only 
necessary  here  to  call  to  mind,  1st,  that  the  bursting  of  an  abnormal 
fruit-sac  is  often  preceded  by  metrorrhagia,  resembling  in  this  respect 
the  more  typical  cases  of  intra-peritoneal  hemorrhage,  in  which  the 
blood  flows  from  the  ovary  or  Fallopian  tube ;  2dly,  that  the  severity 
of  the  injury,  the  quantity  of  the  blood  effused,  and  the  rapidity  with 
which  it  is  poured  out,  induce  such  a  degree  of  shock  that  the  blood 
rarely  becomes  coagulated  and  encysted,  so  that  the  case,  like  that  of 
rupture  of  the  gravid  uterus,  is  "  cataclysmic."  Still  in  some  cases 
there  is  reason  to  believe  that  the  blood  may  coagulate,  become  sur- 
rounded by  plastic  effusions,  and  constitute  a  true  hsematocele. 

The  following  case,  in  which  the  diagnosis  was  verified  by  post- 
mortem examination,  shows  the  possibility  of  a  true  hsematocele  forming 
as  the  result  of  rupture  of  a  tubal  gestation-cyst : 

Fallopian  Gestation — Pelvic  Hcematocele — Death — Autopsy. 

On  the  28th  November,  1867,  I  went  to  Sheerness  to  meet  Mr. 
Swales  and  Mr.  Jaap,  of  Sheerness,  and  Dr.  Jardine,  of  Chatham,  in 

the  case  of  Mrs.  J .     About  a  month  ago,  being  presumed  to  be 

two  months  pregnant,  she  was  taken  with  abdominal  pain  and  flooding, 
but  got  better.  On  the  26th  November,  being  out  at  dinner,  she  was 
seized  with  acute  abdominal  pain,  prostration,  and  was  with  difficulty 
got  home.  The  following  day  she  was  much  worse:  vomiting,  hiccup, 
tympanitis  ;  urine  not  retained  ;  had  calomel  and  mercurial  inunction. 

2Sth. — Pulse  150;  constant  vomiting  and  hiccup;  great  depression. 
The  case  had  at  first  been  taken  for  retroversion  of  the  uterus,  as  the 
OS  was  near  the  pubes,  and  low  down,  and  a  swelling  was  felt  behind 
the  OS,  simulating  the  body  of  the  uterus.  I  passed  a  catheter  into  the 
bladder ;  there  was  no  obstruction.  Per  rectum :  the  cavity  of  the 
sacrum  tolerably  free,  but  there  is  a  firm  swelling  in  the  roof;  this 
swelling  was  also  felt  by  the  vagina ;  the  os  was  open,  admitting  the 
tip  of  the  finger;  it  was  pointing  downwards.  The  sound  curved  enters 
nearly  an  inch  beyond  the  normal  length  in  a  forward  direction,  over 
the  symphysis  :  the  swelling  behind  is,  therefore,  not  the  uterus.  The 
uterus  is  fixed  rather  low  in  the  pelvis,  and  driven  forwards  by  the 
mass  behind. 

Diaarnosis  :  retro -uterine  hsematocele. 

Treatment :  opiate  enemata. 

The  sickness  and  pain  abated  somewhat,  but  otherwise  there  was  no 
amendment.  The  patient  died  under  the  shock  and  loss  of  blood  on 
the  30th.  Mr.  Jaap  wrote  to  inform  me  that  a  "  post  mortem  was  per- 
formed   on  the   2d  December  by  Mr.  Swales,  assisted  by  the  staff- 


PELVIC    HEMATOCELE.  513 

surgeon  of  the  dockyard  and  Mr.  Keddell.  It  must  be  a  melancholy 
source  of  gratification  to  you  to  know  that  your  diagnosis  was  verified 
in  every  iota."  Mr.  Swales,  some  time  after,  communicated  the  follow- 
ing— an  accidental  injury  he  had  sustained  prevented  him  from  mak- 
ing the  minute  examination  he  wished :  "  The  body  was  completely 
blanched ;  I  was  shown  what  was  called  an  adhesion  between  the  left 
Fallopian  tube  and  the  intestines  which  had  been  cut  away  ;  it  certainly 
was  not  an  adhesion,  the  product  of  peritonitis,  about  the  thickness  of 
the  thumb ;  it  was  more  like  half-organized  fibrin ;  the  Fallopian  tube 
had  been  ruptured,  in  my  opinion,  at  the  point  to  which  this  so-called 
adhesion  had  been  attached ;  the  uterus  was  very  pale,  enlarged ;  all 
the  other  organs  healthy  ;  an  immense  amount  of  coagulated  blood  was 
packed  in  among,  and  almost  covering  the  uterus  and  other  pelvic  con- 
tents, besides  which  there  was  a  large  quantity  of  serum.  No  ovum 
was  found.  I  formed  the  opinion  that  it  was  a  case  of  arrested  ovum 
in  the  Fallopian  tube  which  had  escaped  into  the  peritoneum ;  but 
that  she  died  more  from  the  internal  hemorrhage  than  from  inflam- 
mation." 

Here,  as  in  many  cases  of  rupture  of  an  extra-uterine  foetal  cyst, 
there  were  two  distinct  attacks  of  pain  and  shock,  the  first  one  slighter, 
and  giving  hopes  of  recovery  ;  the  second  crushing  and  fatal. 

Another  case  is  quoted  further  on  from  Matthews  Duncan. 

Group  III.  Rupture  of  Diseased  Ovaries. — This  appears  to  be  a  very 
frequent  source  of  the  severer  forms  of  intra-peritoneal  hemorrhage. 
Cystic  ovaries  of  all  sizes  may  rupture.  In  some  cases  the  fluid  effused 
in  chief  proportion  is  that  proper  to  the  cysts,  the  amount  of  blood 
being  inconsiderable.  In  other  cases,  the  large  vessels  in  the  walls  of 
the  cysts  may  be  torn,  so  that  hemorrhage  may  be  great.  In  yet  other 
cases,  there  may  escape  both  blood  in  considerable  quantity,  and  viscid 
or  puriform  matter  from  the  cysts.  In  the  latter  cases,  the  blood  effused 
being  mixed  witli  a  peculiarly  irritating  fluid,  peritonitis  is  sure  to 
ensue  if  the  patient  survives  the  first  shock  of  the  injury.  This  peri- 
tonitis naturally  tends  to  segregate  the  effused  matters ;  but  the  segre- 
gation is  rarely  so  complete  as  in  cases  where  blood  alone  is  effused. 
The  peritonitis  often  takes  the  lead  as  the  more  urgent  disease,  and  is 
commonly  the  immediate  cause  of  death. 

Rokitansky  describes  as  one  source  of  the  blood  in  lisematocele  the 
bursting  of  cysts  of  the  ovary  formed  of  distended  follicles  into  which 
blood  has  been  extra vasated. 

In  those  cases  where  the  blood-effusion  predominates,  the  symptoms 
and  consequences  resemble  those  of  rupture  of  tubal  gestation-cysts. 
There  is  at  first  preponderance  of  shock  over  ansemia ;  and  the  encyst- 
ment  of  the  blood  is  rarely  complete.  But  in  a  case  which  came  under 
my  care  in  St.  Thomas's  Hospital,  and  which  I  have  related  in  detail 
in  the  memoir  above  referred  to,  complete  encystment  did  take  place. 
It  thus  connects  the  series  very  distinctly  with  the  classical  retro-uterine 
lisematocele. 

As  the  case  is  made  complete  by  a  post-mortem  examination,  and  is 
illustrated  by  the  preparation  preserved  in  our  museum,  and  by  a  dia- 
gram, I  think  it  desirable  to  reproduce  it. 

33 


514  PELVIC    HEMATOCELE. 


Retro-uterine  Hcematocele  from  Rupture  of  a  Diseased  Ovary — Punc- 
ture — Death — Autopsy. 

Reported  by  Mr.  Seaton,  Resident  Accoucheur. 

M.  A.  C,  aged  thirty-six,  married,  having  eight  children,  was  ad- 
niitted  into  St.  Thomas's  Hospital,  June  13,  1870,  under  Dr.  Barnes. 
She  had  been  attending  as  an  out  -patient,  and  as  she  had  had  some 
difficulty  in  passing  her  water,  he  deemed  it  advisable  to  take  her  in. 

The  difficulty  in  micturition  was  found  to  have  lasted  for  about 
three  weeks,  and  it  had  now  become  so  great  as  to  necessitate  the  em- 
ployment of  the  catheter.  On  examination  per  vaginam  this  retention 
was  found  to  be  due  to  a  tumor  occupying  a  median  position  in  the 
posterior  wall  of  the  vagina,  in  feel  resembling  the  retroverted  gravid 
uterus.  The  os  was  high  behind  the  symphysis;  the  sound  passed  up- 
wards and  forwards,  over  the  symphysis,  showing  that  the  uterus  was 
compressed  bodily  forwards,  and  was  distinct  from  the  tumor. 

The  history  she  gave  was  that  six  months  ago  she  was  taken  sud- 
denly with  pain  in  the  stomach  whilst  engaged  in  washing,  and  that 
this  happened  at  a  menstrual  period. 

June  23cL — Has  had  some  white  discharge  during  the  last  two  or 
three  days. 

Her  general  appearance  is  much  the  same  as  on  admission.  Her 
complexion  is  straw-colored,  the  eyes  are  sunken  and  surrounded  by  a 
dark  vein.  Pulse  feeble  and  quick  (between  90  and  100).  Appetite 
impaired.     Tongue  pretty  clean.     Is  very  thin.     Skin  dry. 

June  2Sth. — As  the  hectic  condition  persisted,  indicating  that  the 
blood-poisoning  was  progressive.  Dr.  Barnes  punctured  the  tumor, 
which  was  now  distinctly  fluctuating.  A  fine  trocar  and  canula  was 
thrust  into  the  most  depending  part  of  the  tumor.  However,  on  with- 
drawing the  trocar  nothing  came.  Dr.  Barnes,  thinking  that  he  had 
not  put  it  in  far  enough,  punctured  again,  and  this  time  there  flowed 
away  about  two  ounces  or  more  of  dark  treacly  fluid,  like  retained 
menses.  The  canula  was  left  in  for  about  an  hour,  pressure  on  the 
belly  being  made  at  the  same  time  by  a  bandage,  but  very  little  fluid 
beyond  the  above-mentioned  quantity  came  away.  After  the  opera- 
tion, on  examining  by  the  rectum,  the  tumor  was  found  to  have  be- 
come flattened  instead  of  forming  a  bulging  prominence  as  before. 

2dth. — Passed  a  good  night.  No  sickness.  Some  tumefaction  in 
the  vagina  yet,  perhaps  more  than  soon  after  the  puncture.  Pulse  be- 
low 100.  Vagina  feels  hot.  In  afternoon  pulse  went  up  to  120,  and 
temperature  to  103°. 

30^/i._Temperature  104.8°.  Pulse  130.  Mucous  discharge  by 
bowel.  Scalding  micturition.  Tongue  moist.  A  good  deal  of  ten- 
derness over  the  belly.     Poultice  ordered. 

July  1st. — Pulse  125.  Temperature  104°.  Great  pain  in  belly. 
Vomiting.     Bowels  not  open. 

2d. — Pulse  135,  very  feeble.  Temperature  103.6°.  Troublesome 
vomiting.  Enema  returned  without  stool.  Has  passed  water.  Abdo- 
men tense.     A  point  of  emphysema  was  felt  in  tumor  above  the  sym- 


PELVIC    HEMATOCELE. 


515 


physis,  from  which  Dr.  Barnes  diagnosed  that  air  had  got  into  the 
cyst.  The  outline  of  the  fundus  of  the  uterus  was  clearly  distin- 
guished from  the  summit  of  the  tumor  by  palpation.  Appearance 
more  prostrate.     Tongue  coated  with  brown  fur. 

3d. — Vomiting  still,  though  not  so  much.  Tongue  still  coated  with 
brown  fur.  Complains  of  great  pain  in  her  belly,  which  is  a  good  deal 
swollen,  without  giving  fluctuation.  Slimy  discharge.  Pulse,  morn- 
ing 130;  evening,  135.     Temperature,  morning,  102.2°;  evening,  101°. 

^th. — Signs  of  sinking.  Dark  mark  round  eyes  increased.  Pulse 
very  feeble;  scarce  countable.  Vomiting  continues.  Belly  rather 
larger.  Bowels  not  thoroughly  open  yet.  Still  same  slimy  discharge. 
Temperature,  101.4°. 

bth. — Vomiting  worse  than  ever,  allowing  very  little  sleep.  Com- 
plained of  much  pain  to  the  end.     She  sank  at  four  A.M. 

The  autopsy  was  made  on  the  following  day,  and  confirmed  the 
diagnosis.  The  fundus  uteri  was  pushed  forwards  above  the  sym- 
physis ;  behind  it  was  a  tumor,  semi-fluctuating,  which  was  opened  by 
slight  manipulation,  and  then  showed  masses  of  partly  coagulated, 
partly  fluid  blood,  and  some  bubbles  of  air.  This  blood  was  contained 
in  a  cyst,  bounded  above  by  the  intestines,  in  front  by  the  posterior 
wall  of  the  uterus,  behind  by  the  anterior  wall  of  the  rectum,  and 
below  by  the  floor  of  the  pelvis  and  the  depressed    posterior  wall 


St.  Thomas's  Hospital  Museum.    (Dr.  Barnes.) 

Representing  a  retro-uterine  lisematooele  from  a  diseased  ovary. 

u.  The  uterus  pushed  forwards,  a.  The  hsematocele  filling  the  cavity  of  the  sacrum,  bounded  above  by 

plastic  effusions  and  the  small  intestines. 

of  the  vagina.     The  cyst  walls  were  formed   by  peritonitic  plastic 
matter.    The  relations  and  extent  of  the  tumor  will  be  seen  by  the  dia- 


516  PELVIC    HEMATOCELE. 

gram  (Fig.  101),  which,  with  the  assistance  of  Mr.  Stewart,  the  curator 
of  the  museum,  and  of  Mr.  Denison,  librarian,  I  have  constructed  from 
the  preparation  and  my  notes  of  the  examinations  made  during  life. 
No  trace  of  the  right  ovary  could  be  discovered,  unless  a  smooth  ser- 
ous-looking cyst,  projecting  from  and  opening  widely  into  the  main 
cyst,  were  the  remains  of  it.  At  this  point  was  firmly  adherent  a  clot 
of  blood.  It  seemed  to  be  the  source  of  the  hemorrhage;  and  it  was 
concluded  that  the  case  was  one  of  diseased  ovary  which  had  burst,  dis- 
charging blood  into  the  retro-uterine  pouch,  probably  gradually  at  dif- 
ferent intervals.  The  course  of  the  trocar  was  traced  by  small  punc- 
tured wounds ;  it  penetrated  the  lower  posterior  wall  of  the  vagina, 
then  a  small  duplicature  of  the  rectum  before  entering  the  cyst.  In 
another  case  which  came  under  my  care,  a  post-mortem  examination 
showed  that  the  source  of  the  blood  was  a  cancerous  ovary.  The  blood 
was  encysted. 

Group  IV.  Effusions  of  Blood  into  the  Peritoneum  attending  Abortion. 
— During  abortion,  if  there  should  be  any  obstruction  to  the  free  escape 
of  the  blood  from  the  os  uteri,  it  seems  not  improbable  that,  under  the 
extreme  tension  of  vessels  from  increased  turgescence,  escape  may  take 
place  by  the  Fallopian  tubes  into  the  peritoneal  cavity.  These  cases 
naturally  follow  in  order  upon  Group  II.  The  symptoms  are  generally 
less  severe ;  but  they  are  more  severe  than  those  attending  ordinary 
cases  of  impeded  menstrual  function. 

The  following  case  was  very  carefully  observed ;  and  there  is  no 
doubt  on  my  mind  that  it  is  a  good  illustration  of  retro-uterine  hsema- 
tocele  following  on  abortion : 

Abortion — Pelvic  Hcematocele — Recovery . 

On  the  19th  October,  1867,  I  met  Mr.  Burton  of  Blackheath  in  the 
case  of  a  lady  aged  forty-two.  She  had  her  last  child  three  years  ago ; 
labor  natural ;  and  Mr.  Burton  ascertained  that  the  uterus  contracted 
well,  all  being  normal.  Since  then  Mrs.  C.  has  menstruated  regularly, 
not  in  excess ;  no  metrorrhagia  until  July  and  August  last,  when  two 
periods  had  been  missed.  Six  weeks  ago,  when  away  from  home,  she 
had  a  profuse  loss  which  was  taken  to  be  an  abortion.  Since  then  she 
has  suffered  hypogastric  pain,  not  so  severe  as  to  confine  her  to  bed ;  at 
times  there  has  been  difficult  micturition  and  constipation.  She  has 
had  an  attack  of  jaundice,  now  passing  off;  no  marked  fever  or  hectic. 
A  firm  rounded  tumor  rises  to  the  umbilicus,  defined  by  touch  and 
percussion ;  it  is  continuous  with  a  firm  swelling  passing  into  the  left 
ilium.  The  os  uteri  is  soft,  a  transverse  slit  comj^ressed  close  behind 
or  rather  above  the  symphysis  pubis ;  beliind  the  cervix  is  a  large 
rounded  firm  but  not  hard  swelling  filling  the  brim  of  the  pelvis,  and 
partly  projecting  into  the  cavity,  depressing  the  roof  of  the  vagina; 
this  is  also  felt  per  rectum-,  it  is  more  developed  in  the  right  ilium. 
The  sound  gently  curved  passes  three  and  a  half  inches  to  the  fundus 
of  the  uterine  tumor,  by  directing  the  point  well  forwards  round  the 
symphysis  towards  the  umbilicus.  The  uterus,  therefore,  is  in  front, 
enlarged,  and  is  insulated  from  the  larger  mass  behind  it ;  the  uterine 


PELVIC    HEMATOCELE. 


517 


neck  is  pushed  forwards  and  upwards  against  the  pubes  by  the  swell- 
ing, and  the  body  of  the  uterus  is  carried  upwards  so  that  it  is  lifted 
quite  out  of  the  pelvis.  Hence  the  apparent  large  size  of  the  uterus, 
which  seems  to  be  as  great  as  the  uterus  at  four  months'  gestation. 

Diagnosis  :  retro-uterine  hsematocele ;  hemorrliage  beginning  with 
abortion.     Prognosis  favorable.     Treatment :  rest. 

December  dth. — Examined  again ;  uterus  still  enlarged,  in  same 
position,  but  not  rising  so  high ;  the  whole  mass,  uterine  and  retro- 
uterine, movable. 

The  extra- uterine  mass  gradually  disappeared,  the  uterus  recovered 
its  normal  size,  position,  and  mobility. 

The  condition  of  things  is  indicated  in  Figs.  102  and  103,  con- 
structed at  the  time  the  case  was  under  observation. 

Fig.  102. 


Retro-uterine  hsematocele.    (Dr.  Barnes.) 
u,  the  enlarged  uterus  lifted  up  and  pushed  forwards  by  h,  the  retro-uterine  haematocele. 

The  following  is  another  case  in  which  a  discharge  of  blood  per 
rectum  confirmed  the  diagnosis  : 


Abortion — Retro-uterine  Hcematooele — Recovery. 

On  the  6th  October,  1868,  I  met  Mr.  Garman,  of  Bow,  in  the  case 
of  Mrs.  C  B.,  aged  thirty-four,  m^io  had  had  one  child  fourteen  years 
before.  Has  had  several  abortions.  At  the  time  of  my  seeing  her  she 
seemed  to  have  recently  aborted ;  the  uterus  was  three  to  three  and 
a  half  inches  long;  cervix  patulous;  some  hemorrhage;  the  sound 
penetrated  in  normal  direction. 


518 


PELVIC    H.EMATOCELE. 


November  1st. — We  met  again.  Within  the  last  week  there  has 
been  rapid  increase  of  abdomen ;  sense  of  weight  and  forcing  forward 
of  womb  upon  the  pubes ;  pulse  90 ;  no  marked  abdominal  pain,  but 
there  is  a  solid  mass  the  shape  of  the  uterus  rising  to  the  umbilicus ; 
dulness  on  percussion  is  uninterrupted  from  umbilicus  to  pubes.  Per 
vaginam :  fundus  vaginas  depressed,  the  posterior  wall  bulging  forward 
from  pressure  of  a  semi-elastic  mass  behind  and  above  ;  the  cervix  and 
OS  uteri  are  pressed  down  and  forwards  close  to  the  pubes  ;  the  os  is 
flattened  to  a  narrow  chink.  The  sound — an  elastic  bougie — passes 
three  inches  forwards  and  upwards  towards  the  umbilicus.  Per  rectum  : 
a  semi-elastic  rounded  mass  is  felt  filling  the  hollow  of  the  sacrum. 


Sectional  yiew  of  the  parts.    (Dr.  Barnes.) 

The  h^ematocele  fills  the  space  between  the  uterus  and  the  rectum,  and  descends  into  the  pelvic 

cavity,    h.  The  hsematocele.    u.  Uterus,    b.  Bladder,    v.  Vagina,    e.  Rectum. 

Diagnosis  :  pelvic  hsematocele  following  abortion.  Treatment :  rest, 
opiates. 

In  February,  1869,  I  received  a  letter  from  Mr.  Garman  from 
which  the  following  is  an  extract : 

"  Soon  after  your  last  consultation  with  me  Mrs.  B.  passed  a  large 
quantity  of  blood  per  rectum,  which  very  much  relieved  her.  The 
womb  has  gradually  assumed  its  proper  position.  The  catamenia 
appeared  for  the  first  time  ten  days  ago,  and  lasted  the  usual  time,  five 
days,  a  healthy  and  natural  discharge.     She  is  now  convalescent." 

Group  V.  Menstrual  Disturbance  or  Diffi.culty,  leading  to  Effusions 
of  Blood  into  the  Peritoneum. — This  group  includes  by  far  the  largest 
proportion  of  cases.  At  the  same  time  the  danger  is  usually  less,  and 
the  symptoms  are  not  so  severe.  It  may  be  stated  as  a  general  rule, 
that  whenever  there  is  any  impediment  to  the  free  discharge  of  the 


PELVIC    HEMATOCELE.  519 

menstrual  blood  by  the  natural  route,  if  the  quantity  of  blood  exuded 
in  the  uterine  cavity  be  excessive,  or  suddenly  increased  by  accident, 
by  emotion  or  other  causes,  escape  may  take  place  by  the  Fallopian 
tubes  into  the  peritoneum. 

We  thus  get  sub-groups  containing — 

1.  Cases  of  probable  very  early  Fallopian  gestation  and  escape  of 
ovum  into  the  peritoneum. 

2.  Cases  in  which  there  existed  a  mechanical  impediment  to  the 
natural  escape  of  the  menstrual  blood. 

3.  Cases  in  which  there  was  disturbance  or  interruption  of  the 
menstrual  flow  from — 

a.  Cold  and  overexertion. 

h.  From  emotion. 

0.  From  excessive  sexual  intercourse. 

4.  Cases  in  which  the  hemorrhagic  character  of  the  blood  was  in- 
creased by  disease. 

Nelaton  and  Laugier  insisted  that  a  great  cause  of  hseraatocele  con- 
sisted in  the  physiological  work  of  ovulation,  blood  being  poured  out 
from  the  ovary  at  the  seat  of  rupture.  They  enforce  this  theory  by 
observations  which  show  that  in  many  cases  the  first  appearance  of  the 
hsematocele  coincides  with  a  menstrual  epoch ;  that  it  is  especially  at 
the  return  of  the  menstrual  epochs  that  the  gradual  augmentations  of 
the  hgematoceles  take  place ;  that  the  pain  of  menstruation  and  hsema- 
tocele  has  the  common  character  of  pain  in  the  side  of  the  pelvis, 
where  ovulation  takes  place ;  and  that  the  rut  in  animals  may  cause 
an  ovarian  congestion,  followed  by  rupture  of  this  organ,  that  is  to 
say,  accidents  similar  to  those  of  retro-uterine  hsematocele. 

Gallard^  gives  another  explanation  of  catamenial  hsematocele.  He 
contends  that  Laugier  has  exaggerated  the  importance  of  ovarian  con- 
gestion in  putting  it  forward  as  the  principal  cause.  It  is  true,  indeed, 
that  it  always  acts,  but  by  itself  it  is  incapable  of  producing  a  hsema- 
tocele. Gallard,  not  denying  the  efficacy  of  other  causes,  insists  that 
the  principal  cause  of  spontaneous  hsematocele  is  the  dehiscence  of  an 
impregnated  ovule.  According  to  this  view  these  hgematoceles  should 
be  regarded  as  true  extra-uterine  gestations.  This  theory  would,  to  a 
certain  extent,  explain  the  frequency  with  which  hsernatoceles  are  caused 
by  coitus.  Trousseau  even  thought  that  in  these  mild  cases  of  men- 
strual hsematocele  there  was  no  peritonitis ;  such  is  their  benignity. 
They  are  almost  indolent.  But  Bernutz  describes  a  case  in  which  the 
hsematocele  became  encysted  in  thirty-six  hours. 

Dolbeau,  again,  says  retro-uterine  hsematocele  is  a  grave  complaint, 
but  is  rarely  fatal.  A  case  related  by  Sireday  which  occurred  under 
the  observation  of  Aran  proves  that  the  blood  may  coagulate  in  the 
pelvic  region  without  setting  up  peritonitis  at  all.  This  woman  pre- 
sented symptoms  of  intra-abdominal  hemorrhage,  but  no  trace  of  retro- 
uterine tumor  could  be  detected  by  internal  examination  during  life. 
Again,  experience  of  ovariotomists  shows  that  blood  may  be  effiised 
into  the  peritoneal  cavity  without  exciting  inflammation. 


1  "Menioire  sur  les  hematoceles  peri-uterines  spontanees."     1858. 


520  PELVIC    HEMATOCELE. 

In  that  order  of  cases  in  which  the  blood -mass  undergoes  disinte- 
gration, the  symptoms  of  irritative  fever  supervene.  The  temperature 
and  pulse  rise ;  rigors,  vomiting,  sweats  appear ;  and,  unless  a  vent  be 
found  for  the  imprisoned  matter  which  is  poisoning  the  system,  the 
patient  will  be  in  great  danger  of  sinking.  There  is  commonly  a  com- 
plication with  unhealthy  peritonitis.  The  abdomen  becomes  more 
tense,  tympanitic,  and  painful. 

Dissections  demonstrate  that  adhesions  binding  the  uterus  to  the 
rectum  and  neighboring  parts  may  last  for  a  considerable  time,  and 
that  these  remains  are  marked  by  pigmentation  from  hsematoidin.  In 
one  case — it  is  recorded  in  this  chapter — the  fundus  uteri  was  tied  down 
in  retroversion  for  some  months. 

The  blood  may  flow  back  from  the  uterus  and  tubes,  and  escape  by  the 
abdominal  opening  of  the  tubes  under  various  conditions.  The  chief 
of  these  are  obstruction  of  the  tubo-uterine  canal,  and  sudden  excessive 
effusions  of  blood  into  the  tubes  and  uterus,  so  that  the  whole  is  unable 
to  flow  onwards  by  the  vagina  and  vulva. 

The  most  indubitable  cases  of  obstruction  of  the  tubo-uterine  canal 
are  those  of  atresia,  congenital  or  acquired,  of  the  vagina  or  cervix 
uteri.  They  have  been  sufficiently  discussed  under  the  head  of  "  Atresia." 

They  have  been  accurately  described  by  Bernutz.  The  blood  escapes 
into  the  peritoneum  either  by  regurgitation  by  the  abdominal  end  of 
the  tube,  or  by  the  bursting  or  perforation  of  the  tube.  Ruj^sch,  Hal- 
ler,  and  Brodie,  all  believed  that  blood,  menstrual  or  lochia  1,  could 
flow  back  from  the  uterus  into  the  peritoneum.  Trousseau  held  the 
same  opinion.  Basing  upon  his  aphorism  that  "all  physiological 
blood  comes  from  mucous  membranes,"  he  contends  that  the  blood  in 
metrorrhagia  and  abortion  is  simply  blood  in  excess  from  the  same 
source.  Copious  exudation  of  blood  from  the  mucous  membrane  of 
the  uterus  and  tubes,  appearing  as  metrorrhagia,  is,  indeed,  one  of  the 
most  constant  facts  in  the  history  of  the  affection.  Where  this  out- 
pouring of  blood  is  in  excess  of  what  can  be  readily  discharged  by  the 
vagina,  it  is  easy  to  understand  that  some  may  be  driven  back  by  the 
tubes.  The  mechanism  by  which  this  is  effected,  is  probably  the  same 
as  that  by  which  I  have  explained  the  propulsion  of  fluids  injected 
into  the  uterus  along;  the  tubes.  The  uterus  being  suddenlv  irritated 
by  the  invasion  of  a  quantity  of  blood  beyond  its  capacity  to  tolerate, 
contracts  spasmodically,  and  the  fluid  blood  is  propelled  towards  all 
the  three  openings  from  its  cavity.  This  is  borne  out  by  the  history 
of  cases.  The  origin  of  hsematocele  is  often  marked  by  the  initial 
fact  of  a  strong  emotion,  or  physical  shock,  producing  a  sudden  afflux 
of  blood  to  the  pelvic  organs,  followed  by  intense  uterine  pain,  and 
then  by  pain  of  wider  diffusion.  Bernutz's  theory  of  reflux  is  essen- 
tially similar  to  the  above.  The  case  quoted  at  p.  510  from  Olshausen 
is  a  good  illustration. 

But  obstruction  and  retention  of  menstrual  fluid  need  not  be  com- 
plete in  order  to  lead  to  retrograde  escape  by  the  Fallopian  tubes.  In 
the  chapter  on  "  Dysmenorrhoea  "  I  have  drawn  a  comparison  between 
cases  of  complete  and  of  incomplete  retention,  showing  that  the  differ- 
ence between  them  is  one  of  decree  rather  than  of  kind.    Similar  conse- 


PELVIC    HEMATOCELE.  521 

quences  may  be  expected  to  attend  upon  similar  physical  conditions. 
Accordingly  we  find  that  the  narrow  os  externum  uteri,  which  is  so 
frequent  a  cause  of  dysmenorrhoea  by  retention,  may  lead  to  pelvic 
hsematocele. 

Trousseau  has  further  expressed  his  opinion  that  obstruction  from 
retroflexion  of  the  uterus  may  lead  to  hsematocele. 

The  following  case  seems  to  me  to  be  one  of  retrograde  flow  from 
stenosis  of  the  uterus  : 

In  August,  1871,  I  saw,  with  Mr.  Cass,  a  young  lady  who  had  had 
no  child,  but  who  was  said  to  have  had  an  abortion.  She  had  been 
losing  blood  for  a  month.  When  under  exposure  and  fatigue  from 
travelling,  and  there  was  reason  to  conclude  also  from  undue  sexual 
excitement,  she  was  seized  with  pain  in  the  pelvis  which  rapidly  in- 
creased. This  was  followed  by  retention  of  urine.  When  we  met  this 
had  lasted  three  or  four  days.  The  pulse  was  100;  there  was  pain  on 
pressure  above  the  symphysis,  and  in  both  groins.  There  was  an  area 
of  dulness  on  percussion,  and  of  firm  tumefaction  rising  to  the  level  of 
the  umbilicus,  and  extending  into  either  iliac  fossa.  The  uterus  was 
pushed  close  behind  the  symphysis,  the  sound  passed  forwards,  demon- 
strating that  the  fundus  projected  about  two  inches  above  the  symphysis 
pubis.  The  os  was  small,  the  cervix  conical,  presenting  the  characters 
usually  associated  with  dysmenorrhoea  and  sterility.  Behind  the  uterus, 
occupying  the  brim  of  the  pelvis,  and  extending  into  the  hollow  of  the 
sacrum,  was  a  smooth  elastic  swelling.  This  was  also  felt  by  rectum. 
She  had  been  leeched,  and  there  was  a  blister  on  the  abdomen.  There 
had  been  vomiting ;  constipation.  Diagnosis:  retro-uterine  hsemato- 
cele, and  consecutive  pelvic  peritonitis.  We  agreed  upon  sedatives  and 
rest,  and  to  puncture  the  tumor  if  the  pulse  rose.  On  the  next  day 
she  was  sensibly  worse ;  there  was  more  pain  in  the  abdomen,  and  more 
diffused  pain  came  on  rather  suddenly.  The  bladder  now  seemed  re- 
lieved from  pressure,  for  the  urine  was  passed  spontaneously,  and  the 
tense  fluctuating  mass  behind  the  cervix  uteri  was  lessened.  The 
uterus,  in  fact,  was  found  less  tightly  jammed  against  the  symphysis. 
The  pulse  was  130 ;  respiration,  36  ;  temperature,  102°  F.  The  symp- 
toms indicated  a  fresh  shock ;  and  as  the  tension  of  the  tumor  was  less, 
we  did  not  use  the  trocar  as  contemplated.  Under  opium,  the  pulse, 
respiration,  and  temperature  went  down  next  day,  and  she  was  alto- 
gether easier.  At  this  time  I  was  absent  from  town,  and  Mr.  Cass 
subsequently  gave  me  the  following  report :  "  The  tumor  and  symp- 
toms subsided  greatly,  when,  on  the  20th,  menstruation  impending, 
fresh  swelling  and  great  pain  set  in,  and  Mr.  Spencer  Wells  saw  her. 
He  punctured  by  the  vagina ;  a  pint  and  a  half  of  fluid  blood  flowed ; 
the  canula  was  kept  in.  For  three  days  the  discharge  went  on.  When 
the  canula  was  removed  there  was  great  pain.  The  swelling  and  pain 
again  subsided,  and  after  a  long  illness  she  recovered." 

The  following  case  illustrates  the  formation  of  hsematocele  from 
obstructed  menstruation : 

On  the  2d  September,  1863,  I  met  the  late  Dr.  Stevens,  of  Bedford 
Square,  on  the  case  of  a  girl,  aged  fourteen  and  a  half  years,  who  had 
never  menstruated.     She  was  of  tubercular  family.     She  was  appar- 


522  PELVIC    HEMATOCELE. 

ently  in  good  health  three  weeks  before,  not  having  complained  of 
ovarian  or  menstrual  symptoms.  Fourteen  days  ago,  being  then  at 
Margate,  peritonitis  appeared,  and  she  was  sent  home.  Effusion  pro- 
ceeded rapidly.  I  felt  a  firm,  rounded  tumor  rising  above  the  pubes. 
The  catheter  was  passed,  and  the  bladder  emptied,  but  the  tumor  re- 
mained. It  increased  in  size.  When  I  saw  her  again  it  was  as  large 
as  the  uterus  at  three  months'  gestation ;  but  the  pain  and  distension 
from  effusion  were  so  great  as  to  forbid  minute  exploration.  Per  vagi- 
nam,  hymen  permitted  finger  to  pass;  vagina  of  fair  size;  a  somewhat 
firm  mass  was  felt  at  brim  of  pelvis ;  the  os  uteri  could  not  be  clearly 
made  out ;  the  cervix  seemed  distorted  and  compressed  by  the  tumor. 
The  whole  was  slightly  movable  in  connection  with  the  tumor  above 
the  symphysis.  Fluctuation  everywhere  in  the  abdomen,  and  dulness 
in  front;  pulse,  120  to  140;  continuous  expression  of  pain;  prostra- 
tion ;  tongue  dry.  Dr.  Stevens,  having  regard  to  family  history, 
thought  there  was  tubercular  peritonitis.  The  symptoms  seemed  to 
me  too  rapid  for  this.  The  abdominal  shock  and  inflammation  indi- 
cate some  sudden  injury.  Is  it  effusion  of  blood  into  the  peritoneum 
from  the  ovaries,  or  sudden  distension  of  uterus  by  menstrual  fluid, 
with  retention,  ending  in  escape  of  blood  by  Fallopian  tubes,  haemato- 
cele  and  peritonitis  following  ? 

She  died  next  day.     No  autopsy  could  be  obtained. 

Under  the  hypersemic  turgescence  attending  the  onset  of  the  first 
ovulation  and  the  attendant  menstrual  flux,  there  is  a  rapid  transuda- 
tion of  blood  from  the  mucous  membrane  of  the  uterus.  This  organ, 
comparatively  immature  and  unused  to  the  duty  it  is  called  upon  to 
perform,  does  not  readily  expand  to  accommodate  the  blood  poured 
into  its  cavity,  and  which  is  retained  by  an  imperfect  development  of 
the  cervix  from  being  discharged  by  the  natural  outlet.  There  is  con- 
sequently reflux  along  the  Fallopian  tubes,  hsematocele,  and  periton- 
itis. There  can  scarcely  be  a  doubt  that  this  is  the  explanation  of 
some,  at  least,  of  those  apparently  obscure  attacks  of  peritonitis  which 
sometimes  seize  young  girls  at  their  entrance  upon  the  ovarian  epoch. 

The  following  case  of  menstrual  hsematocele  was  observed  to  the  end 
under  such  favorable  circumstances  as  to  furnish  a  good  clinical  illus- 
tration. L.  H.,  aged  thirty-five,  was  admitted  into  my  ward  with 
retention  of  urine  on  the  1st  of  October,  1871.  She  has  had  four  chil- 
dren and  one  abortion.  The  catamenia  have  been  irregular  for  eighteen 
months.  There  is  now  metrorrhagia.  The  uterus  is  driven  forwards 
behind  and  above  the  symphysis  by  a  mass  behind  which  fills  the 
pelvis.  The  os  uteri  is  wide,  gaping;  the  sound  goes  three  inches 
above  the  pubes.  The  mass  is  fixed  in  the  brim  of  the  pelvis,  project- 
ing somewhat  above  the  plane  of  the  inlet.  Her  history  is,  that  five 
weeks  ago,  having  been  menstruating  three  days,  she  was  seized  one 
afternoon  with  intense  pain  in  the  lower  part  of  the  abdomen.  She 
kept  her  bed  ten  days,  then  became  an  out-patient  until  her  admission. 
Early  on  the  morning  of  the  7th  a  considerable  flooding  occurred.  The 
pulse  was  weak,  74,  temperature  99.5°  F.  After  this  the  bladder  was 
relieved  naturally.  On  examination  I  passed  a  sound  three  inches 
through  a  hole  I  felt  in  the  upper  part  of  the  vagina,  behind  the  uterus; 


PELVIC    HEMATOCELE.  523 

the  point  moved  freely  round.  It  was  in  the  cavity  of  the  haematic 
cyst.  By  specukim  we  saw  the  hole,  and  blood  oozing  from  it.  From 
this  time  she  continued  to  improve;  the  tumor  lessened  rapidly  in 
bulk  ;  so  that  on  the  24th  there  was  very  slight  discharge,  the  opening 
had  nearly  closed,  and  the  uterus  had  retreated  to  its  normal  position. 
She  was  again  made  an  out-patient ;  and  we  had  several  opportunities 
of  seeing  the  scar  left  by  the  healing  of  the  opening  by  w^iich  the 
blood-tumor  had  discharged  its  contents.  The  uterus  continued  bound 
down  in  retroflexion  for  some  months.  The  adhesions  were  gradually 
overcome  by  wearing  a  Hodge  pessary. 

Several  curious  examples  have  been  recorded  of  hsematocele  result- 
ing from  dilatation  of  a  tube  where  there  was  a  double  uterus.  M. 
Deces  relates  a  case  of  double  uterus  and  vagina,  in  which  the  left 
vagina  was  imperforate ;  there  was  accumulation  of  menstrual  blood, 
consecutive  dilatation  of  the  left  uterus  and  tube,  and  death  from  rup- 
ture of  the  tube. 

Group  VL  In  which  the  Hemorrhagio  Disposition  is  increased  by 
Disease. — The  influence  of  variola,  as  of  other  zymotic  diseases,  in  dis- 
posing to  hemorrhage,  is  well  known.  "Where  there  is  a  normal  hemor- 
rhagic molimen,  as  from  the  uterus  and  tubes  during  menstruation,  if 
a  zymotic  disease  supervene,  the  normal  flow  is  apt  to  become  hemor- 
rhagic. Barlow  published  a  case  of  pelvic  hsematocele  supervening  on 
purpura  (Edinburgh  Monthly  Journal,  1841);  Scanzoni  one  of  hemor- 
rhage arising  during  measles.  Helie  and  Laboulbene  describe  cases, 
the  first  of  variola,  the  second  of  scarlatina,  in  which  large  clots  were 
found  in  the  uterus,  and  the  Fallopian  tubes  were  distended  by  blood 
coming  from  the  uterus ;  but  there  was  no  blood  in  the  peritoneum. 
These  two  cases  are  cited  by  Bernutz  to  show  that  the  blood  forms  in 
the  uterus,  and  may  flow  back  into  the  peritoneum.  The  hemorrhagic 
tendency  induced  by  small-pox  is  illustrated  in  a  case  related  by  Bouil- 
laud.  A  patient  in  La  Charite,  suffering  from  modified  small-pox, 
was  seized  with  alarming  hemorrhage,  when  the  catamenia  returned 
three  days  after  the  eruption.  I  have  seen  a  case  in  a  young  lady  suf- 
fering from  modified  small-pox.  The  fever  was  severe.  She  was  men- 
struating when  seized.  Next  day  she  was  attacked  suddenly  with  the 
most  acute  pelvic  and  abdominal  pain.  Peritonitis  and  tumefaction 
followed,  and  she  was  for  some  days  in  a  critical  state.  I  have  little 
doubt  that  in  this  case  the  cause  of  the  peritonitis  was  blood-effusion 
into  the  peritoneum.  The  case  is  of  interest  in  this  respect.  Had  the 
symptoms  which  attended  the  effusion  in  this  case  come  on  in  the  course 
of  typhoid  fever  they  would  almost  certainly  have  been  taken  to  indi- 
cate perforation  of  the  intestine.  Is  it  not  possible  that  such  an  error 
has  been  made? 

Bernutz  relates  a  case  of  hsematocele  from  acute  jaundice  in  a  preg- 
nant woman.  When  we  reflect  upon  the  extreme  hemorrhagic  ten- 
dency which  marks  this  dire  disease,  we  cannot  be  surprised  that 
hemorrhage  should  take  this  form. 

In  the  menstrual  cases  it  is  clear  that  fresh  effusions  into  the  perito- 
neum take  place  at  successive  menstrual  epochs,  producing  temporary 
exacerbations  of  the  local  symptoms.     In  these  cases  it  is  probable  that 


524  PELVIC    HEMATOCELE. 

the  subsequent  effusions  do  not  always  take  place  into  the  cyst  formed 
around  the  primary  hsematocele,  but  outside  it,  so  as  to  cause  fresh 
peritonitis.  Hence  those  several  collections  of  blood,  divided  more  or 
less  by  fibrinous  septa,  which  are  sometimes  found  where  there  has  been 
the  opportunity  of  making  a  post-mortem  examination.  In  the  case 
related  as  attended  with  Mr.  Cass  the  menstrual  exacerbations  were 
clearly  observed.    (See  p.  521.) 

A  remarkable  example  of  menstrual  hsematocele  is  that  which  results 
from  effusion  of  blood  from  the  stump  of  an  ovarian  cystic  tumor.  Spencer 
Wells  states  that  his  personal  experience  of  pelvic  hsematocele  has  been 
chiefly  as  a  sequel  of  ovariotomy.  He  believed  the  less  severe  forms, 
where  only  small  quantities  of  blood  are  effused,  and  afterwards  ab- 
sorbed, are  very  common.  When  the  tied  or  cauterized  pedicle,  being 
treated  on  the  intra-peritoneal  plan,  is  in  the  pelvis,  a  good  deal  of 
trouble  is  sometimes  observed  at  each  menstrual  period  for  some  months, 
with  all  the  signs  of  hsematocele.  When  the  pedicle  has  been  treated 
by  clamp  on  the  extra-peritoneal  method,  the  stump  is  occasionally 
seen  to  menstruate,  so  that  we  thus  have  demonstration  of  the  source 
of  the  blood. 

Dr.  Playfair  relates  (Lancet,  1865)  a  very  interesting  case,  in  which 
a  pelvic  abscess  appeared  to  be  the  cause  of  hsematocele.  Following  on 
pelvic  cellulitis  there  was  a  large  discharge  of  pus  by  vagina.  Three 
days  later  there  was  a  sudden  escape  of  a  great  quantity  of  dark-colored 
blood,  the  coagulum  of  which  filled  one-third  of  an  ordinary-sized 
chamber  vessel.  She  eventually  recovered.  He  conjectures  that  blood- 
vessels opened  into  the  sac  of  the  abscess. 

There  are  observations  to  show  that  the  blood  may  flow  from  a  varix 
of  the  broad  ligament.  The  vessels  belonging  to  the  ovary  may  become 
varicose,  and  under  pressure  of  unusual  distension  they  may  burst. 
Richet  and  Ollivier  d' Angers  adduce  evidence  in  point.  Bernutz 
points  out  that  in  cases  of  hsematocele  from  varix  the  accident  comes 
on,  not  at  a  menstrual  epoch,  but  after  fatigue,  which  causes  distension 
of  the  varix.  It  is  certain  that  varix  of  the  pampiniform  plexus,  and 
of  the  plexuses  about  the  vagina  and  vulva,  may  result  from  pregnancy 
and  complicate  varices  of  the  veins  of  the  legs ;  and  there  are  several 
examples  known  of  a  varix  of  a  leg  in  a  pregnant  woman  bursting,  the 
accident  proving  rapidly  fatal.  I  have  myself  known  such  a  case. 
Richet  especially  describes  hasmatocele  as  taking  its  source  in  rupture 
of  varices  of  the  ovarian  or  subovarian  veins.  In  these  cases  the  loss 
of  blood  has  been  so  rapid  and  profuse  that  no  time  has  been  allowed 
for  it  to  become  encysted.  These,  then,  will  swell  the  cataclysmic  order 
of  cases ;  and  by  their  clinical  history  link  hsematoceles  of  ovarian 
origin  with  those  proceeding  from  rupture  of  extra-uterine  gestation- 
sacs.  We  may  then  conclude  that  hasmatocele  from  varix  is  possible  ; 
but  observation  shows  that  it  is  rare. 

Dr.  Tuckwell  records  a  case  related  to  him  by  Seyfert  in  which  the 
blood  came  from  the  rupture  of  a  tubal  vein.  A  maid-servant,  aiged 
eighteen,  while  carrying  a  large  vessel  of  water  on  her  back,  upset  it 
and  received  the  whole  of  its  contents  over  her  back  and  shoulders. 
She  fell  down  suddenly  and  died  rapidly.     The  occurrence  took  place 


PELVIC    HEMATOCELE.  525 

at  the  time  of  the  catamenia.  The  autopsy  disclosed  an  immense  mass 
of  blood  in  the  sac  of  the  peritoneum.  One  of  the  veins  of  the  left  tube 
was  found  to  be  ruptured,  and  a  small  opening  in  the  layer  of  perito- 
neum that  covered  the  tube  had  allowed  the  blood  to  escape  into  the 
abdominal  cavity. 

One  source  of  blood-tumor  has  been  put  forward  on  great  authority 
as  common.  Virchow  affirms  that  the  hlood  exudes  from  the  delicate 
neiv-formed  vessels  of  inflamed  peritoneum;  that  is,  in  fact,  that  there 
has  been  antecedent  peritonitis.  Tardieu  relates  two  cases  in  which  he 
concluded  that  fatal  hemorrhage  came  from  the  peritoneal  surface. 
Bernutz,  however,  does  not  admit  that  these  cases  prove  the  existence 
of  a  hemorrhagic  pelvic  peritonitis.  Schroder  goes  so  far  as  to  affirm 
that  a  tumor  caused  by  a  collection  of  blood,  which  can  be  felt  in  the 
vagina,  can  only  arise  where  a  cavity  is  preformed  for  it;  that  is,  when 
Douglas's  sac  is  first  closed  above  by  a  partial  adhesive  peritonitis. 

I  cannot  help  agreeing  with  Ferber,  who  objects  that  this  preformed 
cavity  is  a  pure  hypothesis.  But  one  cannot  dispute  a  proposition 
made  by  a  pathologist  so  rich  in  experience  and  sagacity  as  Virchow 
without  misgiving.  If,  however,  I  might  venture  to  interpret  my  own 
observations,  I  should  be  compelled  to  conclude  that  the  peritonitic 
source  must  be  extremely  rare ;  and  that  the  general  opinion,  which 
declares  the  peritonitis  to  be  secondary,  not  primary,  is  correct. 

Dr.  L.  Atkin  reports  a  case  (Edinb.  Med.  Journal,  1870)  in  which 
a  hsematocele  seemed  to  be  caused  by  the  use  of  a  laminaria  tent. 

The  influence  of  coitus  has  been  specially  treated  by  French  authors. 
Thus  Voisin  says  that  in  ten  cases  the  commencement  was  traced  to  a 
menstrual  period — i.  e.,  that  in  seven  of  these,  coitus  had  taken  place, 
either  during  menstruation  or  shortly  after,  and  pain  began  during  the 
sexual  act.  Aran  relates  a  marked  case  of  the  kind.  In  one  instance 
observed  by  myself,  I  have  little  doubt  this  cause  was  an  essential 
factor.  In  the  other  three  cases  of  Voisin,  cold,  fatigue,  or  violence, 
daring  menstruation,  seem  to  have  determined  the  attack. 

Group  VII. — I  have  seen  cases  in  which  there  was  reason  to  believe 
that  hemorrhage  was  caused  by  injury  to  the  abdomen.  In  these  cases 
of  direct  violence  it  is  not  easy  to  determine  the  source  of  the  blood 
effused  unless  a  post-mortem  examination  be  made.  Should  the  patient 
be  pregnant  at  the  time,  the  commotion  will  be  likely  to  determine 
hemorrhage  from  the  uterus  or  ovaries.  Of  course,  the  nature  and 
extent  of  pelvic  and  abdominal  lesions  inflicted  by  violence  are  infin- 
itely various.  When  a  student  at  St.  George's  Hospital,  I  saw  a  case 
under  Dr.  Wilson  of  rapid  death  that  ensued  from  the  bursting  of  an 
aneurism  of  the  superior  mesenteric  artery.  The  blood  poured  out  was 
in  great  quantity ;  it  was  diffused  all  over  the  intestines.  There  was 
no  attempt  at  cystic  segregation. 

The  Symptoms  and  Diagnosis. — The  great  variety  of  causes  and  sources 
of  blood-elfusions  into  the  peritoneum  which  we  have  passed  in  review, 
renders  it  manifest  that  we  cannot  lay  down  any  concise  general  sum- 
mary of  symptoms.  Perusal  of  the  cases,  and  comparison  of  the  features 
characteristic  of  the  several  groups  into  which  I  have  arranged  them, 
will  convey  the  best  idea  of  the  significance  of  the  symptoms.     The 


526  PELVIC    HEMATOCELE. 

cases  I  have  pointed  out  may  be  broadly  divided  into  two  great  classes  : 
1.  Those  in  which  an  overwhelming  shock  attends  a  sudden  and  pro- 
fuse loss  of  blood.  This  is  the  cataclysmic  class.  These  cases  generally 
coincide  with  the  non-encysted  class,  the  great  majority  of  which  end 
fatally.  2.  Those  in  which  the  shock  is  less  pronounced,  in  which  the 
eflPusion  is  less  profuse  and  less  rapid,  in  which  general  and  local  signs 
of  inflammation  supervene.  These  form  the  encysted  class,  a  large 
proportion  of  which  end  in  recovery. 

The  history  of  the  first,  or  cataclysmic  class,  is  almost  wholly  com- 
prised in  that  of  rupture  of  the  uterus,  of  extra-uterine  gestation,  and 
of  ovarian  disease.  I  will  not  dwell  upon  it  here.  The  history  of  the 
second,  or  encysted  class,  presents  features  admitting  of  being  defined 
with  great  precision.  It  must  not,  however,  be  lost  sight  of  that  effti- 
sion  resulting  from  menstrual  reflux,  although  usually  falling  within 
this  second  class,  may  be  cataclysmic. 

In  the  encysted  cases,  the  history  may  commonly  be  told  in  three 
chapters.  1st.  There  is  shock  and  pain  referred  to  the  pelvis  and  lower 
abdomen,  and  ansemia.  2d.  There  are  signs  of  reaction,  of  fever,  and 
pain  indicating  peritonitis,  and  usually  attended  by  evidence  of  me- 
chanical obstruction,  as  of  the  bladder.  3d.  There  are  the  signs  attend- 
ing the  disposal  of  the  blood-mass  and  the  inflammatory  deposits. 

1.  A  woman  within  the  reproductive  period  of  life,  during  a  men- 
strual period,  usually  profuse,  after  being  exposed  to  cold,  fatigue,  or 
sexual  excess,  is  seized  suddenly  with  pain  in  the  pelvis.  This  is  at- 
tended by  shock,  inducing  more  or  less  collapse,  according  to  the  sud- 
denness and  profuseness  of  the  loss,  and  the  susceptibility  of  the  patient. 
The  surface  becomes  cold,  the  face  pale,  the  pulse  falls ;  perhaps  there 
is  syncope :  there  is  usually  vomiting.  If  the  loss  be  extensive,  the 
signs  of  hemorrhage,  of  ansemia,  are  added. 

2.  In  the  second  stage,  the  signs  of  reaction  appear.  The  pulse 
rises,  the  skin  becomes  warmer.  There  is  felt  a  sense  of  warmth  or 
burning,  with  distension  of  the  lower  abdomen.  The  pain  persists. 
Frequently  retention  of  urine  occurs,  and  constipation  follows.  Men- 
orrhagia commonly  goes  on.  The  rectum  shows  signs  of  irritation,  a 
dysenteric  condition  is  observed,  marked  by  tenesmus  and  muco-san- 
guineous  discharge.     But  this  is  not  constant. 

Examination  of  the  abdomen  usually  reveals  more  or  less  enlarge- 
ment and  tenderness.  The  enlargement  is  in  the  form  of  a  rounded 
swelling  rising  out  of  the  pelvis  towards  the  umbilicus,  and  stretching 
towards  either  ilium.  In  several  cases  the  tumor  has  risen  quite  as 
high  as  the  umbilicus.  Examination  by  the  vagina  reveals  conditions 
closely  resembling  those  characteristic  of  retroversion  of  the  gravid 
womb  at  the  third  or  fourth  month.  The  finger  cannot  proceed  to- 
wards the  hollow  of  the  sacrum  because  a  rounded  tumor  occupying 
that  space  pushes  the  posterior  wall  of  the  vagina  forwards,  altering 
the  direction  of  this  canal ;  following  this,  the  finger  is  directed  upwards 
and  forwards,  behind  and  above  the  symphysis  pubis ;  and  usually 
closely  compressed  against  the  symphysis  just  behind  it,  or  a  little  be- 
low its  level,  the  os  uteri  is  felt.  In  cases  where  the  cervix  is  soft,  and 
the  OS  large,  this  may  be  flattened  out  into  a  narrow  transverse  chink. 


PELVIC    HEMATOCELE.  527 

The  finger  may  be  able  to  penetrate  by  pressure  in  front  of  the  vaginal- 
portion,  and  also  on  either  side ;  but  the  tumefaction  is  almost  continu- 
ous with  the  posterior  margin  of  the  os  uteri,  seeming  to  form  one  with 
the  uterus,  and  thus  closely  simulating  the  physical  signs  of  retrover- 
sion. In  the  early  stage,  the  tumor  feels  soft  and  fluctuating,  but  it 
soon  becomes  more  tense,  less  resilient,  and  may  eventually  become 
quite  solid.  The  solidity  depends  partly  upon  coagulation  of  the  blood- 
mass,  but  more  especially  upon  the  formation  of  plastic  effusions,  the 
product  of  the  peritonitis  excited  to  segregate  it. 

Before  removing  the  finger  from  the  vagina,  examination  should  be 
completed  by  catheter  and  sound.  The  use  of  the  catheter  may  be  in- 
dicated by  retention  of  urine.  When  the  bladder  is  emptied,  the  way 
is  cleared  for  further  precise  observation.  The  finger  resting  upon  the 
OS  uteri  or  in  front  of  it,  is  opposed  by  the  fingers  of  the  other  hand 
applied  to  the  abdomen,  just  above  the  symjjhysis.  Between  them  the 
body  of  the  uterus  may  usually  be  traced,  since  the  fundus  is  driven 
forward  so  as  to  project  above  the  pubic  symphysis.  But  this  is  made 
quite  clear  by  the  use  of  the  sound.  Passing  this  instrument  into  the 
uterus,  it  is  found  to  penetrate  upwards  and  forwards  for  the  normal 
length  of  two  and  a  half  inches,  or  usually  more,  the  point  being  carried 
directly  over  the  symphysis.  And  now  abdominal  palpation  is  repeated 
with  more  advantage.  The  uterus  supported  on  the  sound,  is  felt  by 
its  fundus ;  pressure  by  the  fingers  upon  this  portion  imparts  a  move- 
ment which  is  plainly  felt  by  the  hand  which  holds  the  sound.  Thus 
no  doubt  remains  as  to  the  position  of  the  uterus.  We  know  for  cer- 
tain that  the  softer,  semi-fluctuating,  or  even,  it  may  be,  solid  mass  be- 
hind the  cervix,  is  not  the  body  of  the  uterus.  Its  rapid  appearance 
under  symptoms  of  shock,  the  quickly  succeeding  signs  of  local  pressure 
and  distress,  tell  us  with  great  certainty  that  it  is  not  a  fibroid  tumor, 
or  an  ovary,  or  an  inflammatory  effusion ;  and  the  knowledge  derived 
from  pathological  studies  tells  us  that  only  blood-eifusion  can  produce 
a  tumor  in  this  situation,  ushered  in  by  the  circumstances,  and  attended 
by  the  local  conditions  described.  Examination  by  the  rectum  carries 
the  diagnosis  to  still  further  precision.  The  finger  is  immediately  met 
by  the  rounded,  more  or  less  yielding  swelling ;  by  this,  the  finger  is 
directed  backwards  along  the  sacral  hollow ;  and  it  is  rare  that  it  suc- 
ceeds in  getting  above  the  tumor,  or  even  beyond  its  equator ;  the  sen- 
sation imparted  by  the  tumor  differs  from  that  of  the  retroverted  uterus 
by  being  less  solid.  In  the  slighter  cases  of  menstrual  heematocele, 
when  the  amount  of  blood  poured  out  is  moderate,  Douglas's  pouch 
may  be  well  filled,  it  will  displace  the  uterus  forwards  and  downwards ; 
but  there  may  be  no  tumefaction  felt  above  the  pelvic  brim.  But  in 
some  cases,  the  swelling,  if  not  early,  still  in  the  progress  of  the  case, 
rises  to  various  points  above  the  level  of  the  symphysis,  even  as  high 
as  the  umbilicus.  In  these  cases,  it  may  be  possible,  with  or  without 
the  help  of  the  sound  in  utero,  to  make  out  the  round  hard  fundus  of 
the  uterus  distinct  from  the  larger  tumefaction  of  the  encysted  hsemato- 
cele.     This  is  illustrated  in  Fig.  101. 

The  enlargement  of  the  tumor  is  not  so  often  effected  by  continuous 
gradation,  as  by  sudden  starts.     At  every  menstrual  epoch,  there  may 


528  PELVIC    HEMATOCELE. 

be  a  fresh  increment,  due  to  renewed  hemorrhage.  This  event  is 
marked  by  reproduction  of  the  symptoms  described  in  the  first  series, 
by  exacerbation  of  distress. 

3.  As  the  case  proceeds,  the  general  and  local  signs  undergo  some 
modification.  Pain  usually  persists,  although  it  may  be  moderated. 
In  cases  tending  to  spontaneous  cure,  irritative  fever  subsides;  the 
pulse  may  fall  to  100,  or  less;  the  temperature  to  100°  Fahrenheit,  or 
less.  Usually  some  degree  of  tenesmus  continues.  More  or  less  me- 
trorrhagia is  common.  As  the  tumor  lessens  in  bulk,  under  the  ab- 
sorption of  its  fluid  elements,  the  uterus  retreats  a  little  towards  the 
middle  of  the  pelvis,  relieving  the  bladder.  Still  the  uterus  is  im- 
movable; and  behind  it  there  is  still  the  tumor. 

Dolbeau  (Medical  Times  and  Gazette,  1873)  thus  accurately  describes 
the  course  of  the  affection  : 

"  The  different  phases  through  which  the  encysted  sanguineous  tumor 
passes  are  revealed  by  signs,  which  must  be  searched  for  with  the 
greatest  attention.  The  induration  and  progressive  diminution  indi- 
cate that  recovery  is  taking  place.  On  the  other  hand,  when  seven  or 
eight  days  after  the  accident  you  can  certify  that  the  tumor  has  become 
soft  and  fluctuating,  you  may  be  quite  sure  that  the  tumor  is  retro- 
grading, and  will  empty  itself  externally.  When,  in  addition  to  the 
softness  which  persists,  fever  adds  itself  to  this  symptom  at  the  end  of 
the  day,  with  a  real  elevation  of  temperature,  shivering,  night  sweats, 
and  a  great  dislike  to  all  kinds  of  food,  you  can  be  sure  that  the  hsema- 
tocele  is  going  to  suppurate ;  and  this  is  a  most  important  point  to 
know  beforehand,  often  indicating  surgical  intervention  to  obviate  sep- 
ticaemia. 

"  Generally  the  tumor  diminishes  in  size  as  it  becomes  harder,  and 
as  it  approaches  recovery.  But  in  some  cases,  after  improving  for 
three  or  four  days,  a  relapse  takes  place ;  the  tumor,  which  seemed  to 
be  getting  gradually  less,  suddenly  increases  in  size,  and  at  the  same 
time  grave  general  phenomena  are  observed.  After  this  interruption, 
the  symptoms  rapidly  ameliorate.  .  .  .  Now,  in  most  cases,  the 
menses  influence  this  retrocession  in  a  curious  manner.  Women  suf- 
fering from  this  complaint  are  quite  regular,  the  menstruation  being 
scarcely  deranged.  In  all  cases,  from  the  moment  the  catamenial  flux 
commences,  a  most  sensible  diminution  takes  place  in  the  size  of  the 
tumor." 

The  tumor  may  disappear  by  absorption,  by  perforation  through  the 
roof  of  the  vagina,  by  perforation  into  the  rectum.  These  issues  are 
the  normal  methods  of  spontaneous  cure.  But  the  blood-mass  may 
undergo  a  process  of  suppurative  or  decomposing  liquefaction,  setting 
up  septicsemia  and  irritative  fever.  Hsematoceles  undergoing  tliis  or 
other  change,  distended  by  fresh  effusions,  under  violence  or  without, 
may  burst  their  cyst,  and  throw  out  the  contents  into  the  general  cavity 
of  the  peritoneum.  This  issue  is  rare,  but  cases  liave  been  recorded. 
It  is  of  course  attended  by  fresh  signs  of  abdominal  injury  and  shock, 
and  is  likely  to  be  quickly  fatal.  Dr.  West  records  a  case.  Tuck  well 
relates  the  following  on  the  authority  of  Seyfert :  A  woman,  in  whom 
retro-uterine  hsematocele  had  been  diagnosed,  was  frightened  by  a 


PELVIC    HEMATOCELE,  529 

patient  in  the  next  bed  being  seized  with  convulsions.  She  sprang  out 
of  bed,  and  at  the  same  moment  felt  a  violent  pain  in  the  abdomen, 
which  was  followed  by  rigor  and  collapse.  Three  days  after  this  she 
died.  The  general  cavity  of  the  peritoneum  was  found  filled  with 
bloody  fluid,  the  blood  having  escaped  from  a  sac  situated  behind  the 
uterus,  which  sac  had  burst.  The  sac  was  formed  by  adhesions  be- 
tween the  rectum  on  the  one  hand,  and  the  uterus,  right  tube  and 
ovary  on  the  other.  It  contained  a  quantity  of  blood,  part  fluid,  part 
in  clots,  in  a  state  of  decomposition.  The  right  ovary,  of  the  size  of 
a  hen's  egg,  and  filled  with  clotted  blood,  was  easily  recognized,  and 
was  found  to  have  burst  and  discharged  its  contents  into  the  cavity  of* 
the  cyst. 

Dr.  Matthews  Duncan  relates  a  case  (Edinburgh  Medical  Journal, 
1864)  of  extra-uterine  gestation,  in  which  signs  of  rupture  occurred  at 
two  and  a  half  months  of  gestation,  followed  by  formation  of  hsema- 
tocele.  A  month  later,  signs  of  fresh  rupture  appeared,  and  death 
followed  in  thirty-six  hours.  Autopsy  revealed  a  tumor  the  size  of  a 
very  large  orange,  between  the  sacrum  and  uterus,  which  contained  a 
foetus  of  less  than  two  months'  development,  and  clotted  blood.  A 
rupture  of  considerable  extent  had  taken  place  in  the  anterior  wall  of 
the  cyst. 

Dr.  Breslau,  of  Munich,  relates  (Mon.  fur.  Geburtsk.,  1857)  a  case 
diagnosed  as  rupture  of  a  haematocele,  followed  by  recovery.     The  ' 
hsematocele,  which  had  been  made  out  before,  quite  disappeared  after 
signs  of  rupture. 

The  specimen  described  from  Bartholomew's  Museum  also  may  be 
referred  to  as  illustrating  the  termination  by  internal  rupture  of  the 
blood-tumor. 

In  some  cases,  the  intra-peritoneal  perforation  seems  to  be  dealt  with 
like  the  original  eifusion,  by  a  fresh  conservative  peritonitis,  which 
surrounds  the  new  effusion  of  blood.  Accordingly,  in  some  cases.  Dr. 
Madge's  is  an  example,  the  blood-sac  seems  divided  into  two  by  a 
septum. 

Two  cases  have  been  recorded,  one  being  that  of  Dr.  Madge,  and 
another  by  Bernutz,  in  which  phlegmasia  dolens  of  one  leg  was  devel- 
oped in  the  course  of  the  affection. 

The  proportion  of  cases  which  disappear  by  absorption  is  hard  to 
estimate.  It  can  scarcely  be  doubted  that  in  some  cases  assumed  to 
have  terminated  in  this  way,  an  opening  was  really  effected  into  the 
vagina  or  rectum,  very  small,  perhaps,  but  large  enough  to  permit  of 
slow  evacuation  of  the  haematic  cyst.  The  process  may  be  so  gradual, 
that  the  moderate  rectal  or  vaginal  blood-discharge  is  not  suspected  to 
come  from  the  cyst.  In  other  cases  the  discharge  by  rectum  or  vagina 
is  manifest  enough.  At  a  variable  time,  ranging  from  two  weeks  to 
two  mouths,  or  moi'e,  blood  escapes  in  one  solid  mass,  or  in  small 
coagula  mixed  with  fluid  portions  over  several  days.  In  one  case  re- 
ported in  this  chapter,  we  had  several  opportunities  of  seeing  blood 
ooze  from  an  opening  in  the  posterior  vaginal  roof;  we  saw  this  open- 
ing gradually  become  smaller,  the  tumor  melting  away  simultaneously, 
and  at  last  only  a  scar  was  left. 

34 


530  PELVIC    HEMATOCELE. 

Dr.  Willoughby  Wade  conjectured  that  in  some  cases  the  blood- 
tumor  liquefying  discharged  itself  by  the  Fallopian  tubes  and  uterus. 
But  distinct  evidence  of  this  is  wanting.  As  we  have  seen,  a  sanguineous 
discharge  from  the  uterus  and  vagina  is  common ;  but  it  may  be  the 
expression  of  the  general  congestion  or  turgidity  of  the  uterus.  It  is 
not  evident  that  it  comes  from  the  cyst  in  the  way  Dr.  Wade  suggests. 

In  some  cases  the  symptoms  are  essentially  the  same,  but  the  general 
and  local  distress  is  less  intense.  The  pain  is  slight,  the  fever  moder- 
ate, the  effusion  is  seldom  large  enough  to  be  felt  above  the  pubes.  A 
few  days,  or  at  most  a  few  weeks,  suffice  for  recovery,  the  tumor  disap- 
pearing almost  as  quickly  as  it  came. 

All  the  best  observers  recognize  this  order  of  cases,  and  hold  them 
to  be  not  infrequent.  Of  the  truth  of  this  I  am  firmly  convinced. 
There  seems  no  valid  reason  to  doubt  that  small  as  well  as  large  quan- 
tities of  blood  may  be  effused  into  Douglas's  pouch ;  and  there  is 
ample  evidence  to  prove  that  small  quantities  of  blood  may  give  rise 
to  only  slight  irritation.  If,  as  Tuck  well  says,  the  objection  be  urged 
that  as  they  do  not  terminate  fatally,  and  are  not  large  enough  to  ne- 
cessitate puncture,  the  presence  of  blood  as  the  cause  of  the  tumor  is 
merely  conjectural,  it  may  be  answered  that  their  close  resemblance  to 
the  more  pronounced  cases,  the  nature  of  which  is  unmistakable ;  the 
position  of  the  tumor ;  and  the  rapidity  with  which  it  is  absorbed,  are 
sufficient  to  justify  the  diagnosis.  Those  who  reject  all  evidence  ex- 
cept that  furnished  by  dissection,  or  by  puncturing  the  tumor,  shut 
themselves  out  from  the  possibility  of  instruction  by  clinical  observa- 
tion and  reasoning. 

In  the  milder  order  of  cases,  and  in  those  which  end  by  discharging 
through  the  rectum  or  vagina,  the  sac  itself  formed  by  peritonitic  effu- 
sions has  to  be  absorbed.  This  is  effected  more  or  less  rapidly  and 
completely. 

The  diagnosis  flows  from  the  appreciation  of  the  symptoms  described. 
It  may  be  affirmed  with  confidence  that  nothing  else  but  a  hsemato- 
cele  will  produce  them  in  their  aggregate  or  cumulative  character.  The 
conditions  most  likely  to  lead  to  error  are : 

1.  Retroversion  of  the  Gravid  Womb. — This  is  the  error  I  have  known 
most  frequently  made.  The  distinction  is  made  out  by  the  physical 
exploration  described  above ;  by  the  history  of  pregnancy  when  there 
is  retroversion ;  and  by  the  absence  of  the  fundus  uteri  from  the  pelvic 
brim  or  from  the  abdomen  above  the  symphysis. 

2.  Fibroid  Tumor. — The  presence  of  the  body  of  the  uterus  in  its 
normal  place,  or  at  any  rate  its  being  made  out  separately  from  the 
tumor  under  investigation,  distinguishes  fibroid  from  htematocele.  The 
history  of  the  two  cases  is  essentially  different.  The  fibroid  is  of  slow 
growth  ;  the  hsematocele  rapid  and  sudden. 

3.  A  small  ovarian  cyst  locked  in  the  hollow  of  the  sacrum  behind 
the  uterus.  By  the  unaided  physical  exploration,  it  is  sometimes  diffi- 
cult to  bring  out  decisive  differential  signs.  A  small  ovarian  tumor  is 
fluctuating,  elastic,  occupies  exactly  the  position  of  hsematocele,  dis- 
places the  uterus  forwards  in  a  similar  manner,  causes  retention  of 
urine,  and  carries  the  vaginal  canal  forwards,  compressing  it.     But 


PELVIC    HEMATOCELE.  531 

there  is  a  difference  in  the  feel  of  the  tumor  manifest  to  the  practiced 
touch ;  the  history  is  different ;  the  symptoms  have  usually  come  on 
gradually.  The  sudden  shock  of  hsematocele,  the  attendant  peritonitis 
are  wanting. 

4.  Perimetrie  Inflammation. — The  invasion  of  this  affection  is  some- 
times very  similar  to  that  of  hsematocele;  indeed  it  may  be  concluded 
that  in  some  cases  of  presumed  perimetric  inflammation  there  is  hsema- 
tocele  as  well.  The  characters  of  perimetric  inflammation  have  been 
described  in  the  preceding  chapter.  It  is  enough  here  to  repeat  that 
the  seat  and  nature  of  the  tumefactions  felt  in  the  vagina  and  rectum 
differ  from  those  of  hsematocele.  They  are  rarely  so  purely  retro- 
uterine; they  are  commonly  lateral,  often  unilateral;  they  fix  the 
uterine  neck  lower  in  the  pelvis,  and  generally  near  the  centre,  or  de- 
viate it  to  one  side;  they  are  more  knobby,  irregular  in  shape;  they 
are  hard,  brawny.  But  in  one  case  N^laton  found  the  walls  of  a  hsem- 
atocele  hard,  like  cartilage ;  and  Madge  describes  the  same  condition. 
Retention  of  urine  is  more  exceptional,  and  in  the  issue  not  blood,  but 
pus  is  voided. 

5.  Abscess  in  the  Neighborhood  of  the  Utei'us. — This  may  be  distin- 
guished by  the  following  differential  signs :  Abscess  is  rarely  so  dis- 
tinctly retro-uterine  as  hsematocele.  In  all  the  cases  I  have  seen  which 
gave  rise  to  doubt  there  was  some  degree  of  laterality.  It  is  not  so 
frequently  connected  with  menstrual  accidents ;  there  is  no  coincident 
metrorrhagia.  It  does  not  attain  suddenly  its  greatest  intensity.  The 
tumor  is  not  formed  from  the  commencement.  The  skin  does  not  sud- 
denly become  anaemic.  The  mass,  hard  at  first,  becomes  later  soft  and 
fluctuating,  the  contrary  being  usually  the  case  in  hsematocele.  The 
constitutional  symptoms  follow  an  inverse  order  from  those  of  hsema- 
tocele.    But  I  have  known  pelvic  abscess  cause  retention  of  urine. 

The  diagnosis  may  in  some  doubtful  cases  be  assisted  by  the  explo- 
ratory needle,  or  Dieulafoy's  aspirator-trocar.  But  this  should  not  be 
lightly  used.  The  finest  puncture  may  set  up  inflammation ;  and  if 
the  blood  have  coagulated,  the  negative  result  might  betray  the  inex- 
perienced explorer  into  the  error  that  the  tumor  was  not  a  hsematocele. 
Should  pus  escape,  the  diagnosis  of  abscess  is  tolerably  certain. 

I  am  tempted  to  add  Dolbeau's  picture  of  the  diagnosis  : 

"  The  diagnosis,"  says  Dolbeau,  "  is  sometimes  very  easy,  at  others 
very  difficult.  Great  importance  must  be  attached  to  the  more  or  less 
advanced  stage  of  the  malady.  If  the  case  is  seen  at  the  commence- 
ment, you  must  bear  in  mind  that  hsematocele  is  not  the  only  uterine 
malady  whose  onset  is  sudden.  The  lypothymic  symptoms,  the  pain 
and  distension  of  abdomen,  occur  in  both  pelvic  peritonitis  and  in 
intense  ovarian  congestions.  Ovarian  congestion  and  hsematocele  are 
never  accomj)anied  by  fever.  Pelvic  peritonitis,  on  the  contrary,  is  a 
malady  essentially  febrile. 

"Position  of  Tumor. — In  hsematocele  it  gives  rise  to  a  projection 
just  above  the  pubes,  and  sometimes  almost  reaches  the  umbilicus. 
The  tumor  in  pelvic  peritonitis  never  extends  beyond  the  level  of  the 
symphysis,  or  if  it  does,  it  extends  slowly ;  whereas,  in  hsematocele, 


532  PELVIC    HEMATOCELE. 

the  tumor  suddenly  attains  its  maximum,  and  afterwards  diminishes 
rather  than  increases. 

"  The  excessive  pallor  of  the  face,  so  important  a  symptom  in  hsema- 
tocele,  is  never  seen  in  pelvic  peritonitis. 

"  The  direction  of  the  cervix  forwards  belongs  exclusively  to  hcema- 
tocele." 

The  treatment  now  admits  of  being  indicated  with  some  authority. 
Disposing,  first,  of  the  cataclysmic  cases,  it  may  be  stated  that  the 
treatment  merges  in  that  of  rupture  of  the  uterus,  of  rupture  of  an 
extra-uterine  gestation-sac,  and  of  other  great  abdominal  lesions.  We 
must  seek  to  rally  from  collapse  by  rest,  by  opium,  and  the  sparing  use 
of  stimulants. 

In  the  milder  class  of  cases  of  true  encysted  hematocele,  as  in  all 
the  other  cases,  rest  is  the  first  and  most  imperative  prescription.  If 
we  suspect  that  hemorrhage  is  proceeding,  we  may  apply  cold  to  the 
abdomen.  When  signs  of  peritonitis  are  coming  on,  salines  and  opiates 
are  of  eminent  service.  As  topical  applications,  leeches  to  the  abdomen 
are  often  of  use;  then  hot  cataplasms  or  fomentations.  Whenever 
there  is  retention  of  urine,  the  indication  to  use  tlie  catheter  is  obvious. 
It  should  be  done  at  stated  intervals — say  every  eight  hours.  If  there 
is  tenesmus  or  dysentery  an  opiate  suppository  should  he  administered. 
Purgatives,  as  breaking  the  law  of  rest,  should  be  sedulously  avoided. 
The  bowels  will  probably  act  by  and  by,  as  in  other  cases  of  obstruc- 
tion, under  the  use  of  opium ;  and  an  enema  may  be  given  after  a  few 
days,  when  the  fecal  accumulation  is  marked. 

The  great  contention  has  been  as  to  the  expediency  of  puncturing 
the  tumor.  Experience  has  gradually  led  to  definite  rules  upon  this 
point.  So  long  as  the  local  distress  is  not  urgent,  so  long  as  the  tumor 
remains  hard,  so  long  as  there  is  no  sign  of  septicaemia  or  irritative 
fever,  so  long  is  it  wise  to  follow  the  expectant  method,  observing  strict 
rest,  and  abstaining  from  all  local  interference.  But  when  the  tumor 
softens,  when  it  enlarges  immoderately,  when  the  pulse  and  tempera- 
ture rising  indicate  septicsemia,  then  it  is  time  to  consider  the  resort  to 
juncture.  This  step  being  resolved  upon,  we  have  to  weigh  the  method 
of  performing  the  operation.  The  most  convenient  spot  to  select  is 
the  most  bulging  part  behind  the  cervix  uteri  in  the  roof  of  the  vagina. 
We  may  use  a  medium-sized  trocar  or  a  bistoury.  The  instrument 
should  be  plunged  in  the  direction  of  the  axis  of  the  pelvic  brim,  par- 
allel with  the  posterior  wall  of  the  uterus.  This  line  can  be  accurately 
defined  by  first  passing  the  sound  into  the  uterus.  We  thus  get  a  land- 
mark. If  the  instrument  be  directed  obliquely  backwards,  it  is  apt 
to  perforate  the  rectum  first,  and  to  enter  the  hEeraatocele  obliquely, 
affording  only  an  imperfect  escape.  It  is  well  to  leave  the  canula  in 
situ  to  serve  as  a  drain.  If  the  blood  be  in  great  part  coagulated,  we 
may  scoop  out  what  can  be  easily  reached  with  tlie  handle  of  a  spoon ; 
but  generally  it  is  wiser  not  to  meddle  too  much. 

In  cases  where  decomposition  arises,  the  sac  should  be  w'ashed  out 
twice  a  day  with  Condy's  fluid,  or  weak  carbolic  acid. 

Out  of  fifty-three  cases  of  recovery  tabulated  by  Tuckwell,  thirty 
were    treated  without  any  operation.      The   remaining   twenty  were 


PROLAPSUS    OF    THE     UTERUS.  533 

punctured.  But  it  is  at  least  doubtful  whether  in  some  of  these  latter 
the  puncture  was  not  superfluous,  whether,  indeed,  it  were  not  a  source 
of  danger. 

One  source  of  such  danger  is  the  admission  of  air  into  the  sac,  and 
the  consequent  decomposition  of  its  contents.  Aran  records  a  case  of 
this  kind  in  which  puncture  was  made  by  an  exploratory  trocar,  a  fis- 
tulous opening  remained,  and  death  ensued  from  putrid  infection. 

Here,  as  in  all  other  pelvic  and  abdominal  inflammations,  it  should 
be  a  standing  rule  to  avoid  repeated  examinations.  Manipulation  must 
disturb  parts  which  above  all  things  require  repose ;  it  can  hardly  fail 
to  irritate  and  aggravate  inflammation ;  it  may  burst  the  blood-cyst, 
and  lead  to  a  fatal  renewal  of  hemorrhage  and  peritonitis. 


CHAPTER   XLIII. 

DISPLACEMENTS  OF  THE  UTERUS;  DEFINITION;  VARIETIES  OF; 

PROLAPSUS  DESCRIBED;    HYPERTROPHY  OF  THE 

VAGINAL-PORTION. 

The  uterus  may  be  said  to  be  displaced  whenever  it  is  removed  from 
its  usual  position  by  some  more  or  less  persisting  cause.  Of  course 
allowance  must  be  made  for  the  normal  mobility  of  the  organ.  Move- 
ment within  certain  limits,  if  followed  by  return  to  the  normal  statical 
position,  is  not  regarded  as  displacement. 

The  displacements  of  the  uterus  are  as  follows : 

Upwards  or  elevation. 

Downwards  or  prolapsus. 

To  either  side  or  lateral  deviation. 

Forwards. 

Backwards. 

In  all  the  above  displacements  the  uterus  may  preserve  its  normal 
form  and  size ;  its  axis  may  remain  unchanged ;  its  shape  may  be  un- 
affected. In  connection  with  displacement  in  reference  to  the  axis  of 
the  pelvis,  the  uterus  may  be  altered  in  its  inclination  :  that  is,  its  fun- 
dus may  be  inclined  forwards,  constituting  anteversion ;  backwards, 
constituting  retroversion  ;  to  either  side,  constituting  right  or  left  lateri- 
version.  These  displacements  are  estimated  chiefly  by  the  deviation 
of  the  body  of  the  uterus  from  its  central  position,  the  cervix  remain- 


534  PROLAPSUS     OF    THE    UTERUS. 

ing  more  or  less  fixed  by  its  axis  of  suspension  to  the  base  of  the 
bladder. 

Displacements  may  be  associated  with  change  of  form.  Thus,  the 
uterus  may  be  bent,  its  axis  undergoing  deviation.  It  may  be  bent 
forward,  constituting  anteflexion  ;  backwards,  constituting  retroflexion  ; 
to  either  side,  constituting  right  or  left  lateriflexion.  The  uterus  also 
may  undergo  torsion  or  twisting  on  its  axis. 

Prolapsus  or  Descent  of  the  Uterus. 

It  will  be  convenient  to  begin  with  the  description  of  prolapsus. 
This  is,  if  not  the  most  common  of  all  the  displacements,  at  any  rate 
that  which  most  frequently  comes  under  treatment. 

In  the  great  majority  of  instances  the  history  is  a  continuous  one, 
beginning  with  labor,  and  marked  successively  by  uterine  engorgement, 
subinvolution,  inflammation,  prolapsus,  retroversion,  and  hypertrophy. 

The  most  rational  and  profitable  course  then  must  be  to  follow  the 
historical  order ;  to  study  first  the  immediate  consequences  of  labor, 
and  then  to  trace  out  the  subsequent  events  to  their  full  accomplish- 
ment.    The  first  chapter  of  this  history  has  been  already  traced. 

The  leading  fact  then  in  the  history  of  prolapsus  of  the  uterus  is 
imperfect  involution  after  labor.  If  this  great  fact  be  kept  steadily  in 
mind,  and  the  lessons  in  practice  which  it  dictates  be  carried  out,  many 
cases  of  prolapsus  will  be  prevented  altogether,  and  many  more  will  be 
arrested  in  their  early  and  most  curable  stages. 

Prolapsus  uteri  of  course  strictly  means  a  falling  of  the  womb.  In- 
stead of  swinging  at  its  proper  level,  it  descends  lower  into  the  pelvis, 
and  may  even  make  its  way  through  the  vulva.  Hence  there  are 
different  degrees  of  descent.  The  minor  degrees  in  which  the  womb 
only  drops  in  the  vagina  are  usually  distinguished  as  prolapsus  ;  whilst 
the  extreme  degrees  in  which  the  womb  passes  forth  through  the  vulva 
bear  the  name  of  procidentia.  Etymologically  viewed,  these  terms 
have  an  arbitrary  significance  assigned  to  them ;  but  it  is  convenient 
to  retain  them  in  the  sense  which  custom  has  associated  with  them. 

Prolapsus  and  procidentia  may  be  more  accurately  defined  as  follows. 
If  we  regard  the  cavity  of  the  uterus  as  a  continuation  of  the  walls  of 
the  vagina,  the  whole  forming  one  tube,  there  will  be,  at  the  commence- 
ment of  prolapsus,  three  duplicatures  : 

1.  A  central  portion,  the  uterus  itself,  dropping  down  into  the  roof 
of  the  vagina,  is  invao-inated. 

2.  Then  there  are  the  two  folds  or  reflections  of  the  vagina,  one  of 
which,  representing  the  part  in  which  the  uterus  is  inserted,  is  carried 
down  inverted  by  the  uterus  ;  the  other  is  the  part  of  the  vagina  which 
retains  its  normal  position,  and  receives  the  inverted  portion  contain- 
ing the  uterus.  So  long  as  this  stage  of  depression,  of  partial  inver- 
sion of  the  vagina  by  the  squatting  of  the  uterus  continues,  there  is 
prolapsus. 

3.  Procidentia  exists  when  the  body  of  the  uterus,  continuing  its 
invagination,  has  passed  quite  through  the  vulva.  When  this  has 
taken  place,  there  are  only  two  duplicatures,  viz.,  the  uterus  which  has 


PROLAPSUS    OF    THE    UTERUS. 


535 


passed  into  the  now  nearly  completely  inverted  vagina:  As  Cruveilhier, 
however,  observed,  some  vestige  of  the  second  duplicature  formed  by 
the  vagina  is  constantly  met  with  in  the  furrow,  of  greater  or  less  depth, 
situated  behind  the  procident  mass  ;  for  though  the  inversion  of  the 


Diagram  illustrating  successive  stages  of  prolapsus  of  uterus,  and  the  attendant  degrees  of 

retroversion. 

A  B.  Axis  of  brim  of  pelvis,    c,  D.  Axis  of  outlet.    B,  E.  Curve  of  Carus,  or  curvilinear  axis  of  pelvis. 
1,  2,  3,  4.  Stages  of  prolapsus.    The  uterus  tethered  to  the  symphysis,  revolves  round  it  in  descent. 

anterior  wall  of  the  vagina  may  be  complete,  that  of  the  posterior  wall 
is  scarcely  ever  so.  Hence  the  tumor  caused  by  prolapsus  uteri,  is- 
alwavs  lono-er  in  the  vertical  direction  in  front  than  it  is  behind.  The 
theory  of  prolapsus  and  procidentia  uteri  may  be  summed  up  as  follows  : 
Invagination  or  intussusception  of  the  uterus  is  prolapsus ;  complete 
inversion  of  the  vagina  or  hernia  uteri  is  procidentia. 

In  complete  prolapsus  the  inverted  vagina  contains  the  uterus. 
This  is  hypertrophied;  its  cavity  is  mostly  enlarged,  filled  with  mucus. 
Besides  the  uterus,  the  vaginal  sac  commonly  contains  in  front  a  por- 
tion of  the  bladder-base ;  behind,  the  anterior  and  lower  part  of  the 
rectum.  Looking  into  the  pelvis  from  above  we  see  between  the  blad- 
der and  the  rectum  into  a  funnel-shaped  cavity,  in  the  depth  of  which 


536 


PROLAPSUS     OF    THE     UTERUS. 


lies  the  fundus  of  the  uterus,  dragging  down  after  it  the  tubes  and 
ovaries. 

Such,  then,  is  the  typical  form  of  prolapsus  and  of  procidentia. 
The  uterus,  by  its  attachment  in  front  to  the  base  of  the  bladder,  is 
tethered  to  the  pubic  bone  by  its  lower  third.  The  consequence  is, 
that  as  the  uterus  descends  towards  the  outlet,  it  must  revolve  round 
the  pubic  bone  as  a  centre.  The  fundus  then  gradually  rolls  back,  so 
that  retroversion  keeps  pace  with  prolapsus,  and  when  prolapsus  has 
merged  into  procidentia,  the  fundus  will  be  directed  backwards  towards 


Fig.  105. 


O  V 

Complete  procidentia  uteri.    (Half-size,  from  St.  George's  Museum.) 

p.  Symphysis  pubis,  b.  Bladder,  v.  Urethra  drawn  almost  vertically  downwards  to  open  into  B', 
a  sacculated  diverticulum  of  bladder  outside  the  vulva,  and  in  front  of  the  procident  uterus,  o  u.  Os 
uteri.    D.  Douglas's  pouch  extended  outside  the  vulva.    O.  The  ovary  dragged  down.    a.  The  anus. 


the  anus,  whilst  the  os  externum  will  be  turned  a  little  forwards.  The 
exact  position  of  the  uterus  at  any  point  of  this  downward  course  may 
be  accurately  determined  by  the  fingers  and  sound.  The  lower  the 
uterus  the  more  the  point  of  the  sound  must  be  turned  backwards  to 
pass  along  its  canal,  and  the  more  easily  Avill  the  fingers  in  the  rectum 
get  above  the  fundus.     When  the  procidentia  is  complete  the  whole 


PROLAPSUS     OF    THE    UTERUS. 


537 


uterus  may  be  grasped  between  fingers  and  thumb,  and  its  contour  and 
size  exactly  made  out,  through  its  sac  of  inverted  vagina. 

The  alteration  in  the  course  of  the  urethra  sometimes  makes  it  diffi- 
cult to  introduce  a  catheter.  The  catheter  passes  backwards  and  down- 
wards into  the  substance  of  the  tumor  to  a  greater  or  less  extent,  ac- 
cording to  the  degree  of  procidentia.  A  good  idea  of  this,  as  well  as 
of  the  appearance  of  the  tumor  of  procidentia,  may  be  formed  from 


Fig.  106. 


O   U 


Prolapsus  uteri,  front  view.    Uterus,  bladder,  and  pelvic  bones  removed  en  masse.    (Half-size,  from 
specimen  in  St.  George's  Museum.) 

p.  Symphysis  pubis.    P,  b.  Fundus  of  enlarged  bladder,    b.  Bladder  opened,  bougie  passed  into  it 
from  u,  urethra.    The  bladder  is  drawn  outside  by  the  uterus  behind  it.    o  u.  Os  uteri. 

Fig.  105,  which  I  have  drawn  from  a  specimen  in  St.  George's  Mu- 
seum. B  represents  the  bladder,  b'  the  pouch,  or  diverticulum,  and 
u  b'  the  deviated  urethra. 

There  is  an  excellent  figure  in  Boivin  and  Dug^s,  showing  a  front 
view  of  a  procident  uterus  and  bladder;  the  bladder  is  laid  open  in  the 
front  of  the  tumor,  and  a  bougie  marks  the  downward  course  of  the 
urethra.  Instead  of  copying  this  I  have  preferred  to  introduce  the 
drawing  from  a  specimen  in  St.  George's  Museum,  which  shows  the 
same  points  equally  well.  Fig.  106. 

The  analogy  between  procidentia  uteri  and  hernia  has  always  at- 
tracted attention.     The  inverted  vagina  is  the  hernial  sac ;  the  uterus 


538  HYPEETEOPHIC    ELONGATION. 

is  the  displaced  intestine.  Not  uncommonly  the  sac  contains  a  mass  of 
small  intestines  besides.  Owing  to  the  peritoneum  descending  below  the 
uterus  and  behind  the  upper  fourth  of  the  vagina  before  it  is  reflected  up- 
wards over  the  rectum,  a  deep  pouch  is  formed,  which  undergoes  great 
extension  as  the  uterus  and  vagina  are  carried  downwards.  This  pouch 
may  receive  an  enormous  mass  of  small  intestine,  so  that  the  external 
swelling  may  be  as  big  as  a  man's  head.  The  intestine  may  be  plainly 
felt  by  its  gurgling.  The  anterior  cul-de-sac  of  the  peritoneum  formed 
by  the  reflection  from  the  bladder  on  to  the  anterior  wall  of  the  body 
of  the  uterus  is  too  shallow  to  admit  the  small  intestines  into  it. 

The  descent  and  inversion  of  the  anterior  wall  of  the  vagina  neces- 
sarily drags  the  base  of  the  bladder  and  urethra  with  it,  causing  saccu- 
lation of  the  bladder  and  deviation  of  the  urethra  from  its  natural 
course.  The  degree  of  displacement,  however,  will  depend  somewdiat 
upon  whether  the  prolapsus  have  taken  place  gradually  or  quickly. 
If  it  have  taken  place  quickly,  the  organs  are  carried  down  bodily  to- 
gether; but  if  the  prolapsus  be  of  slow  production,  the  connective  tis- 
sue uniting  the  vagina  and  bladder  may  yield  and  stretch  a  little,  so 
that  the  urethra  may  not  be  so  much  distorted.  But  in  the  majority  of 
cases  the  base  of  the  bladder  is  so  drawm  down  below  the  level  of  the 
meatus,  that  its  contents  cannot  be  perfectly  voided.  The  constant 
straining  to  accomplish  this  causes  distension  and  the  gradual  forma- 
tion of  a  vesical  pouch,  which  is  partly  outside  the  vulva.  In  this 
pouch  there  is  a  continual  tendency  to  stagnation  of  urine.  This  leads 
to  the  deposit  of  lithates  and  phosphates,  and  the  concretion  of  calculi 
in  the  diverticulum.  But  Cruveilhier  met  with  a  case  in  which  the 
whole  cavity  of  the  undisplaced  portion  of  the  bladder  was  filled  by  a 
calculus.  Golding  Bird  pointed  out  how  it  led  to  formation  of  phos- 
phates and  annnoniacal  urine.  Dr.  G.  Boper  related  to  me  a  case  of 
prolapsus  uteri  et  vesicae,  in  M-hich  the  bladder  contained  several  calculi 
which  could  be  rattled  about  by  the  hand.  A  similar  case  of  complete 
procidentia  with  eversion  of  the  vagina,  and  calculi  in  the  pouch  of  the 
bladder  was  under  my  care  at  the  London  Hospital.  Dr.  West  says 
there  is  also  great  liability  to  kidney  degeneration  as  a  retrograde  con- 
sequence. According  to  Cruveilhier,  the  deviation  of  the  meatus  uri- 
narius  is  less  the  effect  of  the  disjjlacement  of  the  bladder  than  of  the 
anterior  wall  of  the  vagina.     The  bladder  generally  is  greatly  enlarged. 

Although,  according  to  my  own  observations,  prolapsus  and  proci- 
dentia are  distinct  from  hypertrophic  elongation  of  the  uterus,  these 
conditions  are  so  frequently  associated  in  the  same  patient,  and  are 
otherwise  so  intimately  related,  that  it  is  most  convenient  to  describe 
hypertrophy  in  this  place. 

Hypertrophy  of  the  Vaginal-poiiion. 

The  greater  number  of  cases  of  considerable  hypertrophic  elongation 
of  the  cervix  uteri  occur  in  women  who  have  had  children,  and  after 
the  age  of  forty-five  or  fifty,  although  we  see  its  incipient  stages  at  an 
earlier  age.     The  hypertrophic  elongation  observed  in  women,  married 


HYPERTROPHIC    ELONGATION.  539 

or  single,  who  have  never  had  children,  is  of  a  different  form,  and  the 
cases  are  not  very  numerous.     We  may  fitly  describe  this  form  first. 

1 .  The  Hypertrophic  Elongation  of  the  Cervix  Uteri  of  Women  ivho  have 
never  borne  Children. — This  form  may  be  observed  in  comparatively 
young  women.  If,  in  the  majority  of  cases,  it  first  comes  under  obser- 
vation in  married  women,  this  is  commonly  because  before  marriage 
the  malformation,  for  such  I  believe  it  to  be,  lies  quiescent.  When 
the  enlarged  structure  comes  to  be  exposed  to  the  contingencies  of 
married  life,  which  include  possibly  a  considerable  amount  of  direct 
violence,  and  certainly  greater  liability  to  congestion,  distress  arises. 
It  entails  all  the  inconveniences  of  a  foreign  body.  It  may  be  com- 
pared to  a  polypus  in  the  vagina.  It  is  usually  conical  in  shape,  the 
base  starting  from  the  fundus  vaginae,  and  tapering  somewhat  towards 
its  lower  end,  at  the  point  of  which  is  seen  the  os  uteri.  This  is  usu- 
ally a  round  opening,  that  will  barely  admit  the  uterine  sound.  The 
length  of  this  hypertrophied  vaginal-portion  varies  from  an  inch  to 
two  inches,  or  even  more.  The  os  uteri  may  come  nearly  down  to  the 
vulva,  so  that  the  vaginal  canal  may  be  nearly  filled  with  the  protu- 
berance. It  not  uncommonly  happens  as  an  aggravation  of  trouble 
that  the  vagina  itself  is  short.  Thus  the  male  organ  comes  into  vio- 
lent contact  with  it,  or  after  a  time  it  distends  the  posterior  wall  of  the 
vagina,  and  a  pouch  is  formed  in  the  roof  behind  the  cervix  uteri. 
That  the  excessive  leno-th  is  due  to  the  elongation  of  the  vas-inal- 
portion  is  proved  by  the  sound  and  by  the  touch,  which  show  that 
the  body  of  the  uterus  occupies  its  normal  position  in  the  pelvis,  and 
is  of  normal  length.  Under  the  irritation  to  which  it  is  constantly 
subjected  it  first  becomes  the  seat  of  congestion,  then  of  inflammation, 
perhaps  of  abrasion  or  ulceration.  Friction  against  the  vagina  sets  up 
inflammation  in  this  canal,  erosions  of  its  mucous  membrance  occur ; 
copious  muco-purulent  leucorrhoea  and  dysmenorrhoea  and  dyspareunia 
are  sure  to  follow.  The  following  case  observed  at  the  London  Hos- 
pital is  typical:  W.,  aged  twenty-six,  married,  never  pregnant;  is 
harassed  by  menorrhagia  and  profuse  leucorrhoea :  has  complained  of 
prolapsus  and  procidentia  for  two  years.  From  girlhood  always  had 
discharge  and  bearing-clown.  The  vaginal-portion  is  smooth,  round ; 
the  OS  externum  projects  beyond  the  labia  majora;  there  is  no  eversion. 
The  elongated  vaginal-portion  produces  all  the  distress  of  a  foreign 
body  in  the  vagina;  like  a  polypus  it  keeps  up  vaginal  irritation,  and 
induces  expulsive  efforts  which  increase  the  procidentia  and  hyper- 
trophy.    Relief  ensued  on  amputation. 

The  only  effectual  treatment  for  these  cases  where  the  projection  of 
the  elongated  vaginal-portion  is  at  all  considerable  is,  I  believe,  ampu- 
tation. And  the  best  way  of  amputating  is  by  the  galvanic  cautery 
wire.  A  superfluous  structure  has  to  be  removed,  and  amputation  is 
not  only  the  most  complete  method  of  accomplishing  this,  but  also  the 
quickest  and  least  distressing. 

The  operation  is  performed  in  the  following  manner.  (See  Fig.  107.) 
The  patient  is  placed  either  in  the  semi-prone  position  or  in  the  lith- 
otomy position,  and  brought  under  the  influence  of  chloroform.  A 
retractor  is  inserted  into  each  side  of  the  vulva,  whilst  a  Sims's  specu- 


540 


HYPERTROPHIC    ELONGATION. 


liim  pulls  back  the  perineum,  and  exposes  the  vaginal-portion.  This  is 
then  seized  by  a  strong  vulsellum,  and  drawn  outwards,  aided  by  pressure 
by  an  assistant's  hand  above  the  pubes.  The  battery  being  ready,  the 
wire-loop  is  then  adjusted  round  the  vaginal-portion  about  half  an  inch 
below  the  line  of  reflection  of  the  vagina.  When  the  heat  is  turned 
on,  the  wire  is  gradually  screwed  up  until  it  has  severed  the  structure 
included.    The  severed  surface  presents  a  clean  smooth  aspect,  showing 

Fig.  107. 


Representing  one  form  of  hypertrophy  of  the  vaginal-portion,  and  the  application  of  the  wire  for 
amputation  by  galvanic  cautery. 

concentric  rings,  the  marks  of  the  varying  intensity  of  the  cautery  as  it 
made  its  way.  There  is  rarely  much  bleeding,  and  no  special  means 
are  usually  required  to  arrest  it.  Any  protracted  oozing  from  the  sur- 
face of  the  stump  or  a  pumping  artery  is  soon  stopped  by  touching 
with  the  porcelain-cone  made  incandescent  by  the  galvanic  current. 
Further  security  against  bleeding  is  obtained  by  allowing  full  time  for 
the  heated  wire  to  make  its  way  through  the  part,  and  thus  to  secure  a 
rather  prolonged  contact  with  the  surface.     A  pledget  of  cotton-wool, 


HYPERTROPHY    OF    THE    CERVIX    UTERI. 


541 


soaked  in  carbolic  acid  oil,  is  the  only  dressing  required.  The  section 
goes  through  the  expanded  portion  of  the  spindle-shaped  cavity  of  the 
cervix.  This  is  not  very  liable  to  close  during  cicatrization,  but  to 
obviate  this  risk  it  is  desirable  to  insert  an  intra-uterine  pessary,  to  be 


Appearance  of  the  vaginal-portion  after  complete  cicatrization  from  amputation  by  the  galvanic 

cautery.     (Ad.  nat.) 


worn  for  a  month.  The  after-treatment  consists  in  rest  for  a  fortnight 
during  the  process  of  repair  by  granulation  and  cicatrization.  The 
state  of  the  new  os  uteri  must  be  watched  for  some  time  afterwards,  to 
be  sure  there  is  no  undue  contraction. 

The  result  in  my  experience  has  been  satisfactory.  The  inflamma- 
tory symptoms  have  subsided,  the  dysmenorrhoea  and  dyspareunia  have 
been  materially  mitigated. 

2.  Other  Forms  of  Hypertrophy  occur  after  Childbirth. — They  may  be 
said  to  grow  out  of  the  state  of  congestive  hypersemia  and  subacute 
inflammation  of  the  cervix,  which  takes  its  departure  from  labor.  The 
course  to  be  pursued  to  prevent  this  result,  consisting  in  the  cure  of 
the  primary  stage,  has  been  already  described.  If  this  course  be  not 
adopted  the  development  of  hypertrophy  in  some  form,  and  to  a  greater 
or  less  degree,  is  pretty  sure  to  follow.  This  secondary  or  acquired 
hypertrophy  is  slowly  progressive ;  it  may  take  many  months  or  even 
years  to  attain  its  full  extent.  Daring  all  this  time  a  degree  of  endome- 
tritis and  inflammation  of  the  vaginal-portion,  with  vaginal  irritation, 
is  kept  up.  Dysmenorrhoea  frequently  attends ;  more  or  less  dyspareu- 
nia is  common ;  there  are  attacks  of  metrorrhagia ;  and  muco-purulent 
leucorrhoea  is  hardly  ever  absent.  The  increased  bulk  of  the  uterus 
and  the  relaxation  of  the  vagina  and  other  pelvic  structures  give  rise 
to  prolapsus,  perhaps  to  retroversion.  As  in  all  cases  where  there  is 
inflammation  of  the  cervix  the  os  externum  remains  patulous.  Often 
there  is  a  degree  of  eversion  or  of  rolling-out  of  the  lining  membrane  of 
the  cervical  canal';  the  lower  margin  of  the  palmse  plicatse  protrudes 
through  the  os,  and  comes  into  sight  in  the  field  of  the  speculum. 
(See  Fig.  109.)  The  rough  granular  appearance  thus  exhibited,  espe- 
cially when  the  epithelium  investment  is  shed,  as  it  often  is,  is  due  to 
the  prominence  of  the  ridges  of  the  arbor  vitse,  and  to  the  projection 


542 


HYPERTROPHY     OF    THE    CERVIX    UTERI. 


of  the  bared  villi  upon  them,  which  in  the  natural  state  are  levelled 
down  somewhat  by  their  epithelium  covering. 

A  somewhat  similar  appearance  is  produced  when  the  hypertrophied 
lips  are  turned  outwards  in  consequence  of  an  exuberant  growth  of 
the  ovula  Nabothi,  and  acquire  from  the  burst  vesicles  a  red,  angry, 
pitted,  and  furrowed  aspect. 

What  to  the  eye  appears  to  be  procidentia  uteri,  and  was  long  be- 
lieved to  be  procidentia,  is,  in  the  majority  of  cases,  a  hypertrophic 
elongation  of  the  cervix,  which  extends  downwards  until  the  os  exter- 
num and  the  inverted  vagina  protrude  beyond  the  vulva.  It  was  no- 
ticed by  Morgagni,  the  forefather  of  so  many  modern  discoverers.  In 
a  case  he  particularly  described,  he  attributed  the  elongation  to  pro- 
lapsus and  hypertrophy  of  the  vagina.  Levret,  in  1773,  also  described 
it  in  a  memoir  entitled  "  Sur  un  allongement  considerable  qui  survient 
quelquefois  au  col  de  la  matrice." 


Fir.  109. 


Eversion  of  the  mucous  membrane  of  the  cervix  uteri. 


Cloquet  correctly  represents  the  condition  in  a  plate,^  and  Cruveil- 
hier  has  invariably  observed  it.  This  elongation  chiefly  occurs  in  the 
point  of  junction  between  the  body  and  neck,  and  is  accompanied  by  a 
striking  contraction  or  narrowing  of  the  part.  In  the  second  part  of 
his  work  on  pathological  anatomy — the  most  magnificent  contribution 
to  the  science  we  yet  possess — Cruveilhier  gives  another  plate,  and  ad- 
ditional observations,  explanatory  of  the  changes  in  the  relation  of 
parts,  occasioned  by  the  inversion  of  the  vagina,  or  prolapsus  of  the 
uterus.  It  appears  from  his  researches,  that  sometimes  the  elongation, 
and  sometimes  the  depression  of  the  uterus,  aids  in  the  greater  degree. 

He  met  with  cases  in  which  the  lengthening  of  the  uterus  was  so 
considerable,  that  when  the  part  was  viewed  within  the  pelvis  it  seemed 
as  if  it  occupied  its  right  situation.  The  coexistence  of  an  inversion 
or  doubling  of  the  vagina,  without  any  displacement  of  the  womb, 
which  has  only  undergone  elongation,  seemed  to  him  to  prove,  that  in 
certain  cases  at  least,  the  displacement  of  the  uterus  has  its  beginning 
in  the  foregoing  change  of  the  vagina.     The  vagina  becomes  inverted 

^  Pathologie  Chirurgicale,  1831. 


HYPERTROPHY    OF    THE    CERVIX     UTERI. 


543 


on  itself,  like  the  finger  of  a  glove,  by  a  mechanism  precisely  like  that 
which  takes  place  in  intestinal  invaginations.  This  process  has  been 
explained  above. 

This  is  illustrated  in  Fig.  110,  from  a  specimen  in  the  London  Hos- 
pital, in  which  f  represents  the  fundus  uteri  in  situ,  whilst  the  mass 
outside  the  vulva  appears  to  be  the  procident  uterus. 


Fig.  no. 


'/rh.rrr 


Prolapsus  of  uterus,  with  hypertrophic  elongation  and  complete  eversion  of  vagina. 

m.ur.  Meatus  urinarius.    f.  Fundus  uteri,    u.v.  Uterus  covered  by  inverted 

vagina,    o.u.  Os  uteri.    (London  Hosijital,  nat  size.) 


Another  point  observed  by  Cruveilhier  is  the  greater  or  less  deform- 
ity of  the  OS  tincse.  One  of  its  lips,  usually  the  posterior  one,  is  very 
prominent,  whilst  the  other  is  effaced.  This  is  illustrated  in  Fig,  111, 
taken  by  me  from  a  case  under  my  care.  In  some  instances  the  os  is 
reduced  to  a  very  diminutive  aperture.  This  is  mostly  the  case  in 
aged  women,  in  whom  atrophy  probably  preceded  the  prolapsus. 


544 


HYPEETEOPHY    OF    THE     CEEVIX    UTEET. 


Virchow,  in  1847/  described  this  occurrence  as  a  peculiar  form  of 
prolapse,  under  tlie  name  of  prolapsus  uteri  loithout  descent  of  the 
fundus. 

The  connection  between  prolapsus  and  hy])ertrophic  elongation  of 
the  cervical  portion  of  the  uterus  demoiistrated  by  the  illustrious  men 


Fl6.    111. 


Hypertrophy  with  procidentia  of  the  vaginal-portion.    Greater  enlargement  of  the  posterior  lip. 
Development  of  "  hypertrophic  polypi."    (Ad.  nat.  R.  B.) 

whose  names  I  have  quoted,  has  been  since  (1859)  described  with  great 
minuteness  by  Huguier.  He  was,  however,  far  too  absolute  in  his 
statement  that  prolapsus  scarcely  ever  exists.  He  distinguishes  four 
varieties.  The  first  affects  the  body  of  the  uterus  only,  and  may  cause 
prolapsus ;  the  second  invades  the  os  tincse  only,  or  the  sub  vaginal- 
portion  ;  the  third  invades  nearly  the  whole  of  the  neck,  but  especially 
the  supra  vaginal-portion.  When  the  first  and  third  coexist,  they 
make  the  fourth  variety.  To  this  I  may  add  that  hypertrophy  of  the 
body  is  very  apt  to  cause  retroversion,  or  retroflexion,  or  anteversion. 

Stolz,  of  Strasbourg,  in  a  memoir  published'  a  few  months  after 
Huguier's  account  was  read  to  the  Academy  of  Medicine,  described  it 
with  a  completeness  of  detail  which  leaves  but  little  to  be  added. 

The  mode  in  which  hypertrophic  elongation  of  the  cervix  uteri  oc- 


1  Verhandlungen  der  Gesellschaft  fiir  Geburtskunde  in  Berlin,  vol.  ii,  1847. 

2  Journal  hebdomadaire,  Juiii,  1859. 


HYPERTROPHY    OF    THE    V  AGI  N  A  L -PO  RT  ION. 


545 


curs  is  in  many  cases,  I  believe,  as  follows :  The  first  factor  is  arrested 
involution  of  the  uterus.  This  entails  endometritis,  which  in  its  turn 
leads  to  active  hypersemia  and  interstitial  fibrin-eifusions.  Then  a 
process  of  gradual  continuous  eversion  and  growth  of  the  cervix  takes 
place  thus :  the  external  tissues  of  the  cervical  portion  are  fixed  to  the 
bladder  and  the  fundus  vaginae,  and,  being  comparatively  free  from 
liability  to  congestion  and  inflammation,  maintain  their  original  con- 
dition as  to  length  and  relative  position.  The  mucous  membrane,  on 
the  other  hand,  which  lines  the  cavity  of  the  cervix,  is  extremely  vas- 
cular, is  the  primary  seat  of  injury  during  labor,  and  of  congestion 
and  inflammation;  it  becomes  swollen,  with  gorged  vessels  and  serum 
and  fibrin  poured  out  into  its  submucous  layers  ;  hence  there  is  in- 
creased villous  growth,  which  can  only  find  room  by  bulging  out 
through  the  os  tincse. 

The  peculiar  traumatic  condition  of  the  vaginal-portion  of  the  cervix 
caused  by  labor,  combined  with  its  subsequent  special  exposure  to 
disturbance,  is  the  reason  why  the  cervix  is  more  commonly  arrested 
in  its  return  to  the  "normal  condition  than  the  body  of  the  uterus.  It 
has  not  only  to  undergo  involution,  but  it  has  to  repair  damage.  A 
chronic  subacute  inflammatory  process  sets  in,  which  entails  a  perverted 
or  exaggerated  nutrition  of  the  part.     The  watery  part  of  the  serum 


Early  stage  of  hypertrophic  elongation  of  the  cervix  uteri ;  eversion  of  the  lips  exaggerated  by 
their  being  parted  by  the  bivalve  speculum.    (Ad.  nat.    R.  B.) 


effused  into  it  at  the  time  of  the  original  injury  is  absorbed ;  probably 
the  solid  constituents  remain ;  fresh  material,  the  result  of  the  hypersemic 
state  compounded  of  congestion  and  inflammation,  is  added.  Hyperplasia 
results,  and  is  maintained  by  the  irritation  of  an  abraded  surface,  which, 
if  the  term  ulceration  be  objected  to,  is  at  any  rate  distinguished  by 
being  bared  of  epithelium,  by  angry  projecting  villi  easily  bleeding. 

This  growth  or  extension  of  the  cervix  takes  place  from  within  out- 
wards, and  involves  a  process  of  eversion.  That  is,  the  hyperplasia  is 
most  active  at  the  inner  and  lower  part  of  the  cervix.  Growth  being 
in  excess  at  this  part,  eversion  and  elongation  downwards  necessarily 
follow.     Then  the  increased  bulk  and  weight  of  the  organ  favor  descent, 

35 


546 


HYPERTEOPHY     OF     THE    V  AGIIST  AL-PORTION. 


which  is  imperfectly  opposed  by  the  attendant  relaxed  state  of  the 
vagina,  and  the  other  supports  of  the  uterus.  The  presence  of  the 
lower  part  of  the  cervix  near  the  vulva  then  excites  reflex  action,  and 


■minima  "«seiiv 

Form  of  advanced  hypertrophic  elongation  of  the  cervix  uteri.    The  two  lips  being  extruded 
outside  the  vulva,  diverge.    Half-size.    (R.  B.) 

the  consequent  straining  efforts  increase  the  protrusion  and  the  conges- 
tion. In  this  prolapse  the  two  opposing  forces  of  downward  pressure 
upon  the  fundus  uteri,  aided  by  the  increased  weight  of  the  cervix,  and 
of  pulling  up  upon  the  cervix  by  the  fundus  of  the  vagina  and  the 
attachments  to  the  bladder,  tend  still  further  to  promote  eversion  and 
downward  groAvth. 

In  some  cases  the  two  lips  elongate  separately,  so  that  when  a  bi- 
valve speculum  is  introduced,  and  the  blades  are  expanded,  the  two 
lips  are  made  to  diverge,  exposing  the  cervical  cavity  between  them. 
I  have  endeavored  to  represent  this  condition,  which  I  believe  is  fre- 
quent, in  Figs.  112,  113.     The  os  gapes  like  an  alligator's  mouth. 

In  the  earlier  stages,  whilst  the  os  is  still  in  the  vagina,  the  lips  are 
flattened  together  by  the  walls  of  the  vagina  closing  upon  them.  When 
opened  by  the  speculum,  endometritis  is  always  seen.  When  the  part 
has  grown  outside  the  vulva,  the  two  lips  freed  from  outward  compres- 


HYPERTROPHY    OF    THE    V  AG  IN  AL -P  ORTION. 


547 


sion  diverge  and  expose  the  interior  of  the  cervix,  just  as  the  bivalve 
speculum  caused  the  lips  to  diverge  whilst  the  part  was  still  intra- 
vaginal.  This  eversion  is  also  favored  by  the  compression  exerted  by 
the  vulva  above  the  os. 

In  a  memoir  on  "Hypertrophic  Polypi,"^  I  directed  attention  to  a 
circumstance  which  marks  the  extreme  activity  of  the  growth  of  the 
lower  segment  of  the  vaginal-portion.  This  is  the  frequent  association 
of  small  polypi  at  the  os  viteri  with  this  hypertrophy.     They  are  iden- 

FiG.  114. 


Hypertrophic  elongation  of  both  supra  and  infra  vaginal-portions  of  the  cervix  uteri,  with  atrophy 
from  pressure  and  dragging  of  the  cervix,  and  tumefaction  from  strangulation  at  the  os  internum. 
(King's  College  Museum,  No.  9902.     Nat.  size.) 

tical  in  structure  with  the  hvpertrophied  cervix  from  which  they  spring. 
(See  Fig.  111.) 

The  hypertrophic  polypus  of  the  cervix  uteri  then,  is  simply  an 
accidental  outgrowth  from  the  hypertrophic  cervix.     It  differs  in  this 

'  1  St.  Thomas's  Hospital  Keports,  1872. 


548         HYPERTROPHY    OF    THE    VAGINAL-PORTION". 

respect  from  the  fibroid  or  myoma  of  the  body  of  the  uterus.  The 
latter  begins  from  what  may  be  called  an  aberrant  nucleus  in  the  mus- 
cular wall,  and  by  its  own  growth  causes  hypertrophy  of  the  uterus. 
But  I  have  also  noticed  them  occasionally  in  association  with  fibroid 
of  the  body  of  the  uterus. 

These  polypi  sometimes  form  at  a  comparatively  early  period  in  the 
history  of  hypertrophy  of  the  cervix.  Bat  they  are  more  frequent  in 
the  advanced  stages,  and  especially  when  the  elongated  cervix  has  pro- 
truded beyond  the  vulva. 

I  may  here  call  attention  to  a  noteworthy  fact  in  the  history  of 
hypertrophic  elongation  of  the  cervix  uteri.  When  this  condition  has 
reached  its  extreme  limit,  the  cervix  and  uterus  almost  invariably 
measure  exactly  5  in., — that  is,  just  double  the  normal  length.  This 
I  have  demonstrated  so  frequently  to  my  classes  by  the  sound  that  I 
have  come  to  regard  it  as  a  law.  I  have  only  known  two  or  three 
cases  in  which  this  dimension  was  much  exceeded. 

There  are  other  conditions  which  appear  to  cause  hypertrophic  elon- 
gation of  the  uterus.  These  I  have  observed  under  various  conditions 
where  the  uterus  was  exposed  to  displacement  and  pressure,  and  to 
stretching.  In  some  cases  the  first  factor  in  the  process  was  pregnancy. 
For  example,  in  extra-uterine  gestation,  the  uterus,  feeling  the  stimu- 
lus, enlarges ;  and  the  enlargement  is  maintained  perhaps  for  some 
months  by  the  advancing  development  of  the  embryo ;  then  if  the  uterus 
becomes  displaced,  as  by  being  pushed  forwards  or  to  one  side,  adhe- 
sions forming  between  it  and  the  foetal  sac,  elongation  is  pretty  sure  to 
occur.  A  similar  effect  is  produced  sometimes  when  involution  of  the 
uterus  is  prevented  by  pressure  upon  it  from  the  masses  of  plastic 
matter  resulting  from  perimetritis.  Fibroid  tumors  not  uncommonly 
cause  hypertrophic  elongation  by  a  combined  process  of  interstitial 
growth,  stretching,  and  pressure.  Ascitic  fluid  distending  Douglas's 
pouch,  and  thus  causing  a  kind  of  vaginal  rectocele,  may  induce  pro- 
lapsus. 

Another  form  of  hypertrophic  elongation  is  seen  in  Fig.  115. 

In  this  case  the  elongation  chiefly  affects  the  supra  vaginal-portion 
of  the  cervix.  Looking  at  the  part  below  the  reflection  of  the  vagina, 
there  is  little  appearance  of  hypertrophy.  The  long,  thinned,  cylin- 
drical appearance  of  the  cervix  above  the  reflexion  of  the  vagina 
suggests  the  conjecture  that  the  body  of  the  uterus  has  been  dragged 
upwards,  whilst  the  cervix  has  been  grasped  by  the  surrounding 
structures. 

In  some  cases  the  elongation  of  the  vaginal-portion  is  not  uniform ; 
it  affects  the  two  lips  of  the  os  unequally.  The  anterior  lip  may  be 
almost  exclusively  affected.  This  is  thought  to  be  explained  by  its 
being  directly  within  the  influence  of  the  traction  made  on  it  by  the 
prolapsed  bladder.  This  produces  the  singular  appearance  termed  by 
Ricord  the  "  col  tapiroide."  The  inner  surface  of  the  lengthened  lip 
has  a  channelled  appearance,  the  continuation  of  the  cervical  canal. 

The  drawing  (Fig.  116),  accurately  taken  from  a  unique  and  valu- 
able preparation  in  St.  Thomas's  Museum,  illustrates  many  of  the  most 
interesting  features  in   the  history  of  hypertrophic  elongation.     An 


HYPERTROPHY    OF    THE    VAGINAL-PORTION. 


549 


especial  value  of  this  preparation  consists  in  the  relative  position  of  the 
parts  being  perfectly  preserved.  The  changes  undergone  by  the  uterus 
are  remarkable.     The  body  of  the  uterus  is  decidedly  elongated ;  it 


Great  hypertrophic  elongation  of  the  supra  vaginal-portion  of  the  cervix  uteri.    (Bartholomcw'a 
Museum,  No.  32.30.    Nat.  size.) 

F.T.  Fallopian  tubes  also  diseased,    v.  Vagina  containing  spherical  infra  vaginal-portion  of  cervix 
uteri.    c.V.  Cervi.K  uteri  elongated. 


looks  as  if  it  had  undergone  stretching  by  pulling  downwards.  Its 
walls  are  a  little  thickened  ;  its  cavity  is  enlarged,  especially  in  length. 
The  demarcation  between  the  canal  of  the  cervix  and  that  of  the  body 
is  scarcely  distinguishable.  This  may  be  due  partly  to  senility.  The 
cervix  has  undergone  enormous  elongation ;  and  the  part  between  the 
sacculation  of  the  bladder  and  the  rectum  is  remarkably  thinned ;  it 


550 


HYPEETROPHY    OF    THE    V  AGIIST  AL-PORTI  ON. 


looks  as  if  it  had  been  drawn  out,  so  that  its  length  had  been  acquired 
by  pulling,  as  when  we  stretch  an  elastic  tube. 

What  is  the  cause  of  this  elongation  and  thinning  of  the  cervix? 
In  the  first  place,  it  must  be  observed  that  these  two  conditions  do  not 
always  coincide.  If  we  examine  a  case  of  comparatively  recent  forma- 
tion, before  the  subject  has  entered  the  climacteric,  we  shall  not  find 
the  substance  of  the  cervix  thinned.  It  is  a  thick,  firm  cylinder 
throughout  its  length.  On  the  other  hand,  if  we  examine  a  case  of 
long  standing  in  an  old  woman,  we  do  find  this  thinning.  The  con- 
clusion seems  to  be  legitimate  that  the  thinning  is  consecutive.     It  is 


Fig.  116. 


Hypertrophic  elongation  of  the  uterus.    (From  a  specimen  iu  St.  Tliomas's  Museum.    One-third  size.) 


a  process  of  atrophy,  partly  senile,  partly  the  result  of  continual 
stretching  which  bears  upon  the  weakest  point  of  the  canal,  and  partly 
from  constant  pressure  between  the  distended  sac  of  the  bladder  and 
the  loaded  rectum.  I  believe  the  thinning  is  also  caused  by  the  con- 
striction to  which  the  elongated  cervix  is  subjected  where  it  is  embraced 
by  the  vulva. 


HYPERTROPHIC    ELONGATION    OF    THE     UTERUS.      551 

The  entire  length  of  the  uterus  in  this  specimen  is  about  seven 
inches.  The  fundus  and  body  are  somewhat  lower  in  the  pelvis  than 
natural ;  the  body  has  undergone  apparently  very  little  elongation,  the 
chief  excess  of  longitudinal  growth  being  spent  upon  the  cervix.  The 
two  lips  of  the  os  uteri  are  much  hypertrophied  and  somewhat  everted. 
They  form  a  mass  covered  by  the  everted  vagina  outside  the  vulva. 
That  this  is  the  result  of  downward  growth,  not  of  simple  prolapsus 
or  stretching,  is  seen  in  the  condition  of  the  bladder  and  of  the  ante- 
uterine  and  retro-uterine  peritoneal  pouches.  The  base  of  the  bladder 
is  carried  down  along  with  the  down-growing  anterior  wall  of  the  cer- 
vix uteri,  forming  a  sacculated  pouch  below  the  level  of  the  urethra, 
and  therefore  below  the  symphysis  pubis.  The  urethra  is  also  dis- 
torted into  a  curve,  of  which  the  convexity  looks  upwards,  the  blad- 
der-end of  it  being  carried  downwards  along  with  the  base,  so  that  a 
catheter  to  pass  would  have  to  be  directed,  first  a  little  upwards,  then 
backwards  and  downwards.  The  body  of  the  bladder  is  enormously 
enlarged ;  that  is,  its  capacity  is  greatly  increased,  but  its  walls  are 
not  materially  thickened.  The  change  seems  to  be  simply  distension, 
probably  the  consequence,  not  of  actual  obstruction  to  the  passage  of 
urine,  but  to  a  habit  of  long  voluntary  retention  acquired  through  the 
desire  to  avoid  the  irritation  caused  by  the  dribbling  of  urine  over  the 
protruding  mucous  membrane  of  the  everted  vagina.  The  fundus  rose 
as  high  as  the  umbilicus,  and  considerably  higher  than  the  fundus  of 
the  uterus.  The  peritoneum,  descending  behind  the  abdominal  wall, 
is  reflected  upwards  over  the  bladder  at  a  point  about  two  inches  above 
the  symphysis  pubis.  It  descends  behind  the  bladder  quite  down  to  a 
point  on  a  level  with  the  sacculated  pouch  of  the  bladder ;  that  is, 
below  the  level  of  the  lower  margin  of  the  symphysis  pubis.  Rising 
over  the  fundus  uteri,  the  membrane  descends  behind,  forming  a  Doug- 
las's pouch  quite  below  the  vulva.  The  only  part  not  much  disturbed  is 
the  rectum.  Of  course  there  is  no  apparent  vagina,  since  the  down-grow- 
ing OS  and  cervix  uteri  have  carried  the  vagina  before  them,  completely 
everting  it  and  turning  it  into  an  investment  of  the  protruded  parts. 

The  specimen  and  the  drawing  exhibit  very  clearly  the  danger  of 
amputating  the  hypertrophied  cervix.  It  would  not  be  possible  to 
remove  more  than  a  portion  of  the  os  without  opening  the  retro-uterine 
peritoneal  pouch.  It  also  explains  the  difficulty  commonly  encountered 
in  keeping  the  protruded  parts  inside  the  pelvis  by  pessaries.  The 
drawing  exhibits  the  relations  of  the  bladder,  uterus,  and  rectum,  ex- 
actly as  they  were  found  ;  that  is,  in  apposition  with  each  other.  There 
were  no  folds  of  intestine  descending  between  them  in  the  anterior  or 
posterior  peritoneal  pouches. 

The  Etiology  of  Prolapsus,  Procidentia,  and  Hypertrophic  Elongation 

of  the  Uterus. 

It  is  desirable  to  start  with  an  enumeration  of  the  different  circum- 
stances under  which  these  conditions  have  been  observed. 

I  have  seen  prolapsus  uteri  in  virgins  caused,  1,  by  attacks  of  epi- 
lepsy ;  2,  by  violent  coughing ;  3,  by  the  dragging  of  a  polypus ;  4, 


552  PROLAPSUS    OF    THE     UTERUS. 

by  succussion,  as  from  a  fall  upon  the  nates,  and  from  railway  collisions. 
In  the  first,  second,  and  fourth  cases  the  prolapsus  may  be  called  acute. 
It  is  produced  by  sudden  violence,  tending  to  drive  the  uterus  and 
other  pelvic  contents  out  through  the  vulva.  It  is  liable  to  be  attended 
by  acute  inflammation,  and  is  commonly  marked  by  excessive  local 
pain.  5,  by  the  pressure  of  an  ovarian  or  other  tumor  upon  the  uterus ; 
6,  by  habitual  overexertion  during  menstruation,  when  the  local  con- 
ditions resemble  those  of  parturition. 

Dr.  Roberton  and  Dr.  Whitehead,  of  Manchester,  were  consulted 
respecting  a  girl,  aged  fifteen,  who  had  just  received  a  sudden  fright. 
The  entire  uterus  was  beyond  the  vulva  and  external  to  an  intact 
hymen.  It  was  replaced,  and  no  future  inconvenience  resulted.  Dr. 
McClintock,  in  his  valuable  clinical  work  on  "  Diseases  of  Women," 
says  he  has  certainly  seen  three  cases  where  the  displacement  resulted 
solely  from  the  violent  efforts  required  in  defecation  to  overcome  an 
organic  stricture  of  the  rectum. 

But  it  is  during  the  exercise  of  the  childbearing  function  that  pro- 
lapsus is  most  common.  To  the  accidental  causes  which  produce  it  in 
virgins,  are  now  added  causes  springing  from  sexual  relations  attended 
or  not  by  pregnancy.  The  dominant  feature  of  these  causes  is  increase 
of  bulk  arising  from  physiological  or  morbid  congestion,  from  inflam- 
mation, from  imperfect  involution  after  labor;  this  is  primarily  or 
secondarily  attended  by  relaxation  of  the  structures  which  support  the 
uterus,  including  the  ligaments,  and  above  all  the  vagina  and  the  con- 
nective tissue  of  the  pelvis.  The  vagina  alone,  if  in  a  state  of  healthy 
contractility,  will  maintain  the  uterus  in  situ  ;  but  when  its  contractility 
is  impaired  by  overdistension,  and  by  inflammation,  the  uterus  squats 
down,  or  sinks  in  it,  producing  a  minor  degree  of  vaginal  depression 
or  inversion.  The  close  attachment  of  the  anterior  wall  of  the  cervix 
uteri  to  the  base  of  the  bladder,  making  the  point  of  union  the  most 
fixed  point  or  centre  of  movement  of  the  uterus,  renders  it  impossible  for 
the  cervix  to  fall  without  dragging  the  base  of  the  bladder  down  with  it. 

In  discussing  the  etiology  of  prolapsus  great  importance  is  usually 
laid  upon  the  study  of  the  mechanism  by  which  the  uterus  is  suspended 
in  its  place.  The  attachments  of  the  uterus  have  been  described  in  the 
anatomical  summary.  We  have  seen  that  it  is  slung  or  suspended  in 
the  folds  of  the  broad  ligaments  to  the  sides  of  the  pelvis,  and  steadied 
to  a  certain  extent  by  the  round  ligaments  in  front,  and  the  utero-sacral 
ligaments  behind ;  that  it  is  in  a  manner  balanced  upon  the  vagina, 
which,  in  its  healthy  state,  forms  an  elastic  muscular  column  of  con- 
siderable strength  ;  that  it  is  attached  by  its  anterior  wall  to  the  base 
of  the  bladder ;  and  that  it  is  further  supported  by  what  may  be  called 
the  padding  of  the  pelvis,  constituted  by  the  connective  tissue  between 
the  peritoneal  folds,  the  vessels,  nerves,  and  other  organs.  No  doubt 
the  proper  preservation  of  the  position  of  the  uterus  is  due  to  the  in- 
tegrity of  all  these  structures.  The  power  of  the  vagina  as  a  support 
to  the  uterus,  and  as  an  agent  in  restoring  it  to  its  place,  is  capable  of 
demonstration.  When  the  speculum  is  introduced,  the  widening  of  the 
vagina  produced  by  it,  shortens  the  canal  and  brings  the  uterus  down; 
as  the  speculum  is  being  withdrawn,  the  vagina  is  seen  to  contract 


PROLAPSUS    OF    THE     UTERUS.  553 

strongly  behind  it,  and  the  consequent  restoration  of  the  organ  to  the 
normal  columnar  state  carries  the  uterus  up  again.  And  we  may  at 
any  time  by  strong  astringents  restore  the  vagina  to  its  original  con- 
dition. 

AVest  further  insists  that  the  curved  direction  of  the  vagina,  and  the 
angle  at  which  the  uterus  is  inserted  into  it,  afford  a  further  obstacle 
to  prolapsus ;  whilst  at  either  extremity  the  vagina  is  strengthened  by 
its  connection  through  the  medium  of  the  pelvic  fascia  with  the  blad- 
der and  rectum  above,  and  by  the  sphincter  which  surrounds  it  below, 
as  well  as  by  the  other  muscles  of  the  pelvic  floor  and  by  the  perineal 
fascia  between  the  two  layers  of  which  those  muscles  lie. 

The  value  of  experiments  on  the  dead  body  designed  to  show  how 
the  uterus  maintained  its  position,  notwithstanding  that  the  vagina  was 
cut  away,  as  by  Hohl  and  others,  or  after  division  of  the  ligaments, 
seems  to  me  to  be  exaggerated.  It  is  clearly,  indeed,  proved  that  the 
uterus  cannot  be  dragged  out  of  the  vulva,  unless  considerable  force, 
amounting,  says  Le  Gendre,  to  from  thirty  to  one  hundred  pounds,  be 
used.  But  it  is  also  certain  that  the  broad  ligaments  must  at  the  same 
time  undergo  great  stretching  or  be  severed.  The  conditions  of  the 
living  body  are  widely  different.  In  the  dead  body  there  is  no  turges- 
cence  from  vascular  fulness,  elasticity  of  tissue,  muscular  contractility, 
constant  movements  from  respiration,  and  the  varying  states  of  the 
bladder  and  rectum ;  indeed,  all  the  conditions  as  we  meet  them  in 
practice,  are  wanting.  Deductions  drawn  from  experiments  upon  the 
dead  body  can  only  be  applied  with  great  caution  and  reserve.  For 
solution  of  the  main  questions  we  must  rely  upon  clinical  observations. 
In  the  great  majority  of  cases  prolapsus  is  accomplished  by  small  forces 
acting  continuously  or  with  brief  intermissions  over  long  periods  of 
time. 

The  fact  that  prolapsus  does  not  occur  in  healthy  structures,  except 
under  the  influence  of  direct  force,  points  to  the  necessary  conclusion 
that  the  sustaining  tissues  of  the  uterus  lose  their  power  of  resisting  a 
down-bearing  force  through  changes  wrought  in  them  by  disease.  With 
the  knowledge  of  these  two  factors:  force,  acting  upon  tissues  weak- 
ened by  disease,  the  explanation  of  the  mechanism  of  prolapsus  is  not 
far  to  seek.  Tlie  downward  force  is  always  acting.  It  is  exerted  at 
every  expiratory  effort,  and  is  exaggerated  by  coughing,  or  by  strain- 
ing at  stool ;  by  every  exertion,  in  short,  which  fixes  the  chest.  If  the 
resistance  be  diminished,  the  pelvic  organs  will  be  carried  down,  the 
ligaments  will  undergo  gradual  stretching,  and  the  vagina,  wanting 
tone  and  contractility,  squats  down  under  the  pressure,  the  uterus  sink- 
ing into  it.  Then  the  force  of  gravity  is  added,  and  is  always  at  work 
when  the  body  is  in  the  upright  posture. 

The  vagina,  then,  is  a  passive,  not  an  active,  factor  in  the  production 
of  prolapsus.  It  yields  and  permits  prolapsus,  because  its  contractility 
and  power  of  resistance  are  weakened.  It  does  not  cause  prolapsus, 
although  when  prolapsus  has  begun,  it  may  aid  the  subsequent  steps 
of  the  descent.  This  discussion  is  not  without  practical  interest,  be- 
cause the  knowledge  of  the  mechanism  by  which  prolapsus  is  brought 
about  must  govern  the  principle  of  treatment.     In  studying  the  con- 


554  PROLAPSUS     OF    THE    UTEEUS. 

ditions  of  treatment,  the  first  thing  that  strikes  us  is,  that  we  cannot 
act  directly  upon  the  broad  and  other  ligaments.  We  cannot,  in  nau- 
tical phrase,  brace  up  or  tauten  these.  We  must  act  from  below.  Hence 
we  are  reduced  to  two  principal  sets  of  mechanical  expedients.  The 
first  set  comprises  the  mechanical  supports,  as  pessaries,  which  help  to 
lift  up  the  uterus  and  anterior  wall  of  the  vagina.  The  second  set 
comprises  the  various  methods  of  strengthening  the  vagina  so  as  to 
restore  its  power  of  supporting  the  uterus. 

The  efficacy  of  the  vagina,  especially  of  the  muscular  posterior  wall 
which  includes  the  perineum,  in  sustaining  the  uterus  will  be  clear  to 
any  one  who  will  remember  the  opposition  it  offers  to  the  descent  of 
the  child's  head  in  labor.  Nor  can  any  one  who  has  felt  the  thick  firm 
inclined  plane  in  which  muscle  so  largely  enters,  formed  by  the  peri- 
neam  and  the  posterior  vaginal  wall,  doubt  its  power  to  support  the 
anterior  wall  of  the  vagina  and  the  uterus.  We  may,  in  fact,  feel  the 
uterus  resting  upon  it.  Thus,  when  this  inferior  support  is  lost,  as 
when  the  perineum  is  lacerated,  the  tendency  to  prolapsus  is  greatly 
increased ;  and  we  find  the  use  of  an  external  perineal  pad,  which  acts 
as  a  substitute  for  the  perineum,  of  signal  service  in  supporting  the 
uterus. 

We  see  that  in  virgins,  force  alone  exerted  upon  healthy  structures 
is  enough  to  cause  prolapsus.  This  force  obviously  comes  from  above. 
It  is  produced  by  the  pressure  of  the  intestines  upon  the  uterus,  bladder, 
and  broad  ligaments  propagated  from  the  diaphragm  and  abdominal 
walls. 

Now,  this  force  which  acts  alone  in  a  certain  number  of  cases,  enters 
as  an  important  factor  into  every  case.  It  acts,  of  course,  with  especial 
advantage  after  labor,  when  the  bulk  and  weight  of  the  uterus  are  in- 
creased, and  when  all  the  tissues  are  relaxed.  After  labor  at  term,  and 
after  abortion,  the  mobility  of  the  uterus  is  enormously  increased. 
Any  one  who  has  frequently  been  called  upon  to  remove  a  retained 
placenta  in  abortion,  will  have  satisfied  himself  upon  this  point.  The 
uterus  is,  in  the  first  place,  at  a  lower  level  than  usual ;  and  in  the 
next,  the  most  moderate  traction  will  draw  it  down  to  the  vulva  with 
a  facility  unknown  at  other  times.  This  implies  that  the  broad  and 
other  ligaments  are  elongated  and  more  yielding,  and  that  the  vagina 
is  relaxed. 

For  the  above  reasons  I  am  of  opinion  that,  in  the  majority  of  cases, 
prolapsus  of  the  uterus  is  a  primary  affection.  But  there  are  facts 
which  favor  the  view  more  prevalent  in  Germany,  which  is,  that  pro- 
lapsus is  secondary  upon  prolapsus  of  the  vagina.  For  example,  if  we 
examine  a  woman  who  is  subject  to  procidentia  when  the  mass  is  within 
the  vulva,  and  tell  her  to  bear  down,  we  see  the  anterior  wall  of  the 
vagina  appear  first ;  that  is,  there  is  apparent  vaginal  cystocele  pre- 
ceding the  appearance  of  the  uterus.  It  is  inferred  that  the  vagina 
drags  down  the  uterus.  The  vaginal  cystocele  is  also,  it  is  said,  the 
first  condition.  I  suspect  there  is  a  fallacy  in  some  of  these  observa- 
tions. If  by  the  hand  in  the  vagina  we  watch  the  course  of  events 
during  an  expulsive  effort,  we  feel  the  uterus  borne  bodily  down  under 
the  force  of  the  superincumbent  pressure.     Of  course  the  uterus  and 


PEOLAPSUS    OF     THE     UTERUS.  555 

bladder,  being  intimately  adherent,  must  descend  together.  The  vagina 
can  only  be  forced  downwards  through  pressure  exerted  upon  the  uterus, 
or  bladder,  or  both.  It  is  possible,  of  course,  that  frequent  pressure 
exerted  by  the  distended  bladder  may  push  down  the  anterior  wall  of 
the  vagina,  which  in  its  turn  will  drag  down  the  uterus.  But  that 
such  a  process  is  not  frequent,  seems  to  be  proved  by  the  fact  that  one 
almost  constant  factor  in  prolapsus  uteri  is  enlargement  and  increased 
weight  of  the  uterus,  which  must  necessarily  destroy  the  balance  between 
the  forces  that  suspend  the  uterus  and  those  that  tend  to  drive  it  down. 
This  correlation  being  destroyed,  the  uterus  cannot  but  fall,  and  it  is 
unnecessary  to  invoke  an  independent  or  superfluous  force,  such  as  the 
downward  dragging  of  the  vagina. 

I  have  frequently  made  the  observation  with  such  care  that  I  am 
sure  of  the  fact,  namely,  that  the  earlier  stages  of  hypertrophic  elonga- 
tion of  the  cervix  are  accomplished  whilst  there  is  no  perceptible  descent 
of  the  bladder,  no  bladder  distress,  and  no  prolapsus  of  the  anterior 
vaginal  wall.  I  have  even  seen  cases  of  marked  hypertrophy  of  the 
lips  without  j^erceptible  prolapse.  I  have  also  seen  the  converse,  that 
is,  decided  vaginal  cystocele,  the  anterior  vaginal  wall  rolling  out  under 
straining,  without  any  hypertrophic  elongation  of  the  cervix.  There 
is  not,  therefore,  any  necessary  connection  between  the  two  conditions, 
since  each  may  exist  without  the  other.  I  go  further,  and  afiii'm  that 
hypertrophy  of  the  vaginal-portion  may  take  place  independently  of 
prolapsus  of  the  uterus. 

Symptoms,  Effects,  and  Course  of  Prolapsus. 

When  prolapsus  is  produced  suddenly,  the  symptoms  attending  are 
generally  complicated  with  the  effects  of  the  accident  which  caused  the 
displacement.  Thus,  when  produced  by  a  fall  or  concussion,  there 
may  be  other  injury  besides  the  prolapsus,  and  there  is  always  more  or 
less  shock.  Then,  the  sudden  succussion  occasions  violent  stretching 
of  the  uterine  supports.  As  these  are  all  connected  with  the  peritoneum, 
inflammation  of  this  membrane  is  very  likely  to  follow;  there  will  be 
severe  pain  over  the  whole  abdomen,  especially  acute  in  the  pelvis, 
tenesmus,  or  bearing-down,  perhaps  uterine  hemorrhage,  and  severe 
febrile  symptoms  ;  and  bladder  and  bowel  distress. 

Sometimes  the  parts  quickly  resume  their  normal  position,  especially 
if  rest  in  the  horizontal  posture  be  duly  observed.  But  this  will  not 
always  be  the  case.  The  uterus  may  have  been  driven  through  the 
pelvis  with  such  force  as  to  break  through  the  hymen ;  and  the  uterine 
ligaments,  once  stretched,  do  not  quickly  recover  their  pristine  condi- 
tion. Moreover,  the  general  health  may  be  so  affected  by  the  shock 
and  local  injury,  that  the  recovery  of  tone  of  the  muscles  and  other 
tissues  will  be  retarded  by  impaired  nutrition. 

When  prolapsus  takes  place  slowly,  the  symptoms  are  less  acute. 
As  prolapsus  is  surely  attended  by  antecedent  or  consequent  engorge- 
ment, or  other  morbid  state  of  tissue,  the  symptoms  of  course  are  a 
complication  of  effects  depending  upon  the  tissue-changes,  and  of  me- 
chanical effects  due  to  the  displacement..    The  first  class  of  symptoms 


556  PROLAPSUS    OF    THE    UTERUS. 

will  be  described  in  their  appropriate  place.  The  mechanical  condi- 
tions are  traced  to  dragging  and  to  pressure.  The  uterus  having  lost 
the  support  of  the  vagina,  and  of  what  may  be  called  the  padding  of 
the  pelvis,  drags  upon  the  utero-sacral  and  broad  ligaments,  which  are 
stretched  and  elongated.  In  the  upright  posture,  especially,  and  under 
bodily  exertion,  the  prolapsus  is  necessarily  increased ;  the  sense  of 
dragging  and  bearing-down  is  then  aggravated.  At  stool  and  during 
micturition,  some  additional  difficulty  being  felt  from  the  pressure  of 
the  uterus,  greater  straining  is  exerted  to  empty  the  bladder  and  rectum. 
The  uterus  itself  being  larger  and  pressing  upon  the  lower  part  of  the 
vagina  and  near  the  anus,  excites  reflex  irritation,  the  response  to 
which  is  seen  in  increased  bearing-down  or  expulsive  efforts.  The 
uterus,  in  fact,  acts  now  as  a  foreign  body.  Its  presence  in  a  situation 
not  accustomed  to  receive  it,  is  resented,  and  the  effort  at  ejection 
increases  the  displacement,  and  constitutes  a  main  difficulty  in  treat- 
ment. The  dysury  and  dyschezia}  increase  in  proportion  as  the  patient 
continues  in  an  upright  posture,  and  as  the  uterus  descends  nearer  to 
the  vulva.  Besides  these  reflex  effects  upon  the  motor  nerves,  the 
patient  feels  pain  from  the  congested  state  of  the  uterus,  from  its  pres- 
sure upon  surrounding  organs,  from  dragging  upon  the  peritoneum. 
These  pains  are  intra-pelvic,  sacral,  dorsal,  and  lumbar,  partly  from 
indirect  pressure  upon  the  pelvic  nerves  and  sacral  plexus,  partly  from 
irritation  of  the  ganglionic  nerves,  and  partly  from  the  spinal  exhaus- 
tion, resulting  from  continual  irritation. 

The  congestion  often  leads  to  menorrhagia,  or  even  to  hemorrhages 
in  the  intermenstrual  periods ;  and  leucorrhcea  is  hardly  ever  absent. 

When  the  uterus  in  its  descent  comes  to  press  upon  the  vulva,  the 
muscles,  the  elastic  tissue,  and  mucous  membrane,  and  skin  which 
surround  and  constitute  the  walls  of  this  opening,  undergo  distension. 
Under  continual  pressure  the  opening  enlarges,  the  perineum  especially 
is  thinned  out,  it  dilates,  is  partially  everted,  and  rounded.  The  con- 
tractility of  the  vulva  is  greatly  impaired ;  the  floor  of  the  pelvis  no 
longer  gives  adequate  support  to  the  structures  above  it.  Prolapsus 
then  easily  passes  into  procidentia.  The  inverted  vagina  becomes  vir- 
tually a  hernial  sac,  which  receives  the  uterus  and  often  a  n)ass  of 
small  intestines.  Although  the  peritoneum  is  drawn  down  so  low  that 
Douglas's  pouch  is  outside  the  vulva,  the  stretching  of  the  ligaments 
having  been  very  gradual  and  slow,  a  degree  of  accommodation  and 
tolerance  has  been  acquired,  so  that  the  pain  of  dragging  may  be  even 
less  than  during  the  early  stages  of  prolapsus.  The  uterus  being  now 
outside  the  range  of  the  sphincters,  the  reflex  expulsive  efforts  and 
pains  may  also  be  less  troublesome.  The  subjective  symptoms  change 
in  character.  The  local  symptoms  are  different.  Under  great  exer- 
tions in  the  upright  posture,  the  dragging  upon  the  peritoneum  may  be 
very  severe. 

The  swelling  protruding  between  the  thighs  is  at  first  of  an  oblong, 
nearly  cylindrical  form,  and  terminates  below  in  a  narrow  extremity, 
in  which  a  transverse  opening,  the  os  tincse,  may  be  discerned.     At  a 


1  Difficult  defecation,  from  (5"?  and  xel,<o. 


PROLAPSUS    OF    THE     UTERUS.  557 

later  period  it  has  a  pyriform  appearance.  The  vagina  turned  inside 
out,  which  forms  the  investment  of  the  swelling,  changes  its  character 
and  appearance.  From  exposure  to  the  air,  the  moist  villous  character 
of  mucous  membrane  is  lost;  the  surface  becomes  dry,  in  places  shi- 
ning. There  is,  as  Virchow  describes  it,  a  histological  transformation. 
The  soft  epithelium  gives  way  to  epidermis,  the  histological  equivalent. 
Often  there  are  patches  of  inflammation  and  ulceration.  These  patches 
get  covered  with  a  thin  pellicle  resembling  cuticle.  It  is  a  kind  of 
scab.  If  peeled  oflP,  the  surface  easily  bleeds.  Sometimes  ulcerations 
occur  where  they  are  easily  overlooked,  namely,  in  the  fold  at  the  base 
of  the  prolapsus,  especially  at  the  posterior  part.  I  have  seen  nodular 
irritable  ulcerations  here  which  disappeared  under  rest. 

The  patches  are  usually  described  as  being  the  result  of  friction,  of 
chafing  against  the  thighs  and  dress,  and  of  urinous  irritation.  I  have 
certainly  seen  sores  formed  on  the  most  depending  part  of  the  tumor 
where  it  was  exposed  to  chafing  on  sitting  down  ;  and  on  either  side 
where  it  came  into  contact  with  the  thighs.  That  this  is  so  in  many 
cases  1  think  I  have  satisfied  myself  from  observation.  But  Dr.  Mat- 
thews Duncan^  contends  that  "  in  the  majority  of  instances  these  con- 
ditions have  nothing  to  do  with  it.  Many  of  the  so-called  ulcerations 
are  not,"  he  says,  "  what  they  appear  to  be.  They  are  red  inflamed 
parts,  covered  by  a  pellicle  of  lymph  or  diphtheritic  membrane,  whose 
contraction  raises  around  the  red  portion  a  redder  and  prominent 
margin,  which  increases  the  likeness  of  the  whole  to  what  is  known  on 
the  skin  as  a  callous  ulcer.  This  diphtheritic  pellicle  may  frequently 
be  raised  and  peeled  off.  Sometimes  it  dries  and  forms  a  translucent, 
horny,  hard,  elastic  plate,  which  becomes  at  last  spontaneously  de- 
tached." He  adds,  however,  "  The  final  termination  of  these  diph- 
theritic inflammations  may,  no  doubt,  be  ulceration." 

The  walls  of  the  vagina  get  thickened,  partly  from  hypertrophy, 
partly  from  infiltration  and  retention  of  serum  in  the  connective  tis- 
sue. This  is  an  effect  of  the  dependent  position ;  the  vessels  can  with 
diflficuity  return  the  blood  poured  into  them.  The  stretching  smooths 
out  the  rugae.  The  mass  has  often  a  dark-red  or  even  a  purple  color, 
but  is  often  pale. 

The  friction  of  the  mass  against  the  clitoris  is  at  times  a  source  of 
distress. 

Chronic  inflammation  of  the  uterus  is  a  frequent  concomitant.  The 
uterus  becomes  painful  to  pressure.  Its  situation  exposes  it  to  vio- 
lence, which  may  induce  acute  inflammation.  This  may  also  be  in- 
duced by  the  use  of  improper  pessaries,  and  the  inflammation  may 
extend  to  the  surrounding  tissues.  Inflammation  of  Bartholini's  glands 
is  not  uncommon. 

The  mass  outside  may  be  seized  with  gangrene,  the  result  of  strangu- 
lation at  the  vulva.  After  prolonged  exertion  in  the  upright  posture, 
the  parts  get  full  of  blood,  the  return  being  impeded  by  the  attendant 
swelling  of  the  labia  vulvae.  I  do  not  think  this  event  is  common. 
But  we  have  recently  seen  a  remarkable  example  in  St.  Thomas's  Hos- 

1  On  "Procidentia  of  the  Pelvic  Viscera,"  Edinb.  Med.  Journal,  1872. 


558  PROLAPSUS     OF    THE    UTERUS. 

pita].  A  very  large  part  of  the  surface  of  the  procident  mass  fell  into 
sphacelus.  The  labia  vulvae  were  tumid,  showing  the  dull  red  of  ery- 
sipelas or  threatening  gangrene.  The  patient  sank  in  a  few  days.  The 
autopsy  was  performed  by  Dr.  Payne.  The  sphacelus  had  involved 
nearly  the  whole  surface  of  the  inverted  vagina,  and  in  some  places  per- 
foration had  almost  been  accomplished.  The  uterus  had  undergone  no 
marked  hypertrophic  elongation.  Nearly  the  whole  of  the  organ  had 
been  contained  in  the  inverted  protruded  vaginal  sac.  The  bladder 
was  greatly  enlarged ;  there  was  retrograde  dilatation  of  the  ureters 
and  of  the  pelves  of  both  kidneys. 

This  affection  of  the  bladder  and  kidneys  is  one  of  the  consequences 
of  procidentia,  when  the  base  of  the  bladder  is  drawn  down,  forming  a 
pouch  outside  the  vulva. 

As  a  general  fact,  it  may  be  stated  that  the  tendency  of  prolapsus  is 
towards  aggravation.  The  cases  of  spontaneous  cure  are  rare.  The 
only  qualification  of  this  proposition  applies  to  the  minor  degrees  of 
prolapsus,  induced  by  childbearing  and  other  causes.  Some  cases 
have  been  cured  by  sloughing  of  the  vaginal  walls,  and  the  consequent 
cicatricial  contraction  of  the  canal.  Prolapsus  may  also  be  said  to  be 
removed  when,  cancer  supervening,  the  spreading  disease  seizes  the 
surrounding  parts,  and  keeps  the  uterus  fixed  in  the  pelvis. 

The  changes  induced  in  the  organs  concerned  in  prolapsus  are  well 
described  by  Scanzoni.  The  vagina,  uterus,  and  broad  ligaments, 
bladder  and  rectum  being  removed  from  the  pelvis,  we  are  struck  with 
the  size  of  the  uterus,  and  with  the  expansion,  relaxation,  and  want  of 
elasticity  of  the  vagina.  The  vagina  has  lost  its  rugse ;  its  surface  is 
usually  smooth,  often  livid,  and  if  the  prolapsus  has  lasted  long  in  an 
extreme  degree,  it  is  very  dry,  covered  with  a  thick  layer  of  pavement- 
epithelium  which  gives  to  the  mucous  membrane  the  aspect  of  epider- 
mis. The  vaginal-portion,  commonly  hypertrophied,  often  indurated, 
but  sometimes  very  swollen  and  softened,  is  of  bluish-red  or  slate- 
gray  color;  around  the  orifice  it  is  deprived  of  epithelium  and  cov- 
ered with  erosions  and  ulcerations.  Often,  after  a  long  persistence  of 
the  disease,  a  true  inversion  of  cervix  is  produced ;  the  orifice  begins 
by  being  sensibly  dilated ;  its  borders  form  a  circle  an  inch  or  more  in 
diameter  through  which  the  cervix  is  inverted,  so  that  the  mucous 
membrane  peculiar  to  the  neck,  covered  by  its  vitreous  secretion  is 
seen.  A  section  of  the  uterus  displays  considerable  hypertrophy  with 
engorgement.  The  cavity  is  always  much  dilated,  especially  length- 
wise, and  the  mucous  membrane  shows  chronic  catarrh. 

There  is  also  frequently  follicular  inflammation  at  the  os  uteri  in  the 
younger  women.  But  in  the  more  aged  the  follicles  have  commonly 
undergone  atrophy  after  bursting. 

Since  the  publication  of  Huguier's  description  of  hypertrophic  elonga- 
tion of  the  uterus,  some,  I  might  say  many,  physicians  have  not  only 
accepted  this  description  as  true,  which  it  undoubtedly  is,  but  they 
have  accepted  it  to  the  exclusion  of  the  old  theory  of  prolapsus.  This 
is  not  a  very  philosophical  process.  One  theory  does  not  necessarily 
expel  the  other. 

Three  conditions  may  exist  in  apparent  procidentia  uteri:  1.  Hyper- 


DIAGNOSIS.  559 

trophic  elongation  of  the  cervical  portion  of  the  uterus.  This,  of  course, 
is  attended  by  eversion  of  the  vagina,  the  fundal  portion  of  which  is 
drawn  down  by  the  advancing  os  uteri.  2.  The  case  may  be  one  of 
eversion  of  the  vagina,  the  pouch  formed  by  which,  projecting,  some- 
what in  the  form  of  a  sausage,  contains  the  uterus  at  the  bottom,  per- 
haps of  normal  size,  or,  as  in  aged  women,  atrophied.  3.  There  is 
equally  inv^ersion  of  the  vagina;  the  pouch  outside  the  vulva  contain- 
ing the  uterus  retroflexed  or  doubled  up. 

The  distinction  between  these  three  cases  is  easily  demonstrable.  In 
the  case  of  hypertrophic  elongation,  if  we  pinch  the  tumor  upwards 
from  the  os  uteri,  we  may  trace  the  elongated  cervix  as  a  hard  cord  up 
into  the  pelvis  as  far  as  the  finger  and  thumb  will  reach.  If  we  then 
introduce  the  sound,  we  find  this  instrument  will  pass  up  along  the 
uterine  canal  quite  into  the  pelvis,  until  its  point  is  arrested  about  on 
a  level  with  the  pelvic  brim — that  is,  the  sound  will  usually  run  a 
length  of  five  inches.  If  we  turn  the  point  of  the  sound  when  thus 
arrested  towards  the  anterior  abdominal  wall,  we  may  generally  feel 
the  fundus  of  the  uterus  by  pressing  a  hand  in  to  meet  it  above  the 
pubes.  We  also  know  when  the  point  of  the  sound  has  reached  the 
fundus  uteri  by  the  sense  of  resistance;  and  by  gently  continuing  the 
pressure  we  produce  a  degree  of  re-inversion  or  re-position.  We  see 
the  everted  os  uteri  turn  inwards,  and  the  mass  outside  becomes  dimin- 
ished in  length.  It  is  needless  to  say  that  this  demonstration  must  be 
conducted  with  great  care,  lest  we  injure,  or  even  perforate,  the  uterus. 

The  second  condition,  that  of  pure  procidentia  uteri,  may  be  recog- 
nized by  the  fingers.  First  the  fingers  compressing  the  tumor  can 
trace  the  included  uterus  by  its  hardness,  and  determine  with  precision 
its  form,  size,  and  position  ;  the  fingers  get  all  round  the  uterus,  grasp- 
ing it  completely,  and  thus  demonstrating  that  it  is  wholly  outside  the 
vulva.  Secondly,  the  sound  again  takes  measure  of  the  uterus,  and 
proves  that  there  is  no  elongation ;  that  it  is  two  and  a  half  inches  long, 
or  barely  a  little  more.  In  the  third  condition,  that  of  procidentia  of 
the  retroflexed  uterus,  the  diagnosis  is  made  out  in  a  similar  way. 

Since  I  meet  all  these  three  conditions  in  nature,  I  cannot  accept 
any  doctrine  which  absolutely  excludes  one  of  them  as  impossible. 
The  real  question  to  settle  is  the  relative  frequency  of  their  occurrence. 
I  believe  the  hypertrophic  elongation  is  the  most  frequent,  but  I  can 
give  no  numerical  data. 

The  two  conditions  arise  under  different  circumstances.  Although 
both  are  observed  in  women  in  the  decline  of  life,  the  hypertrophic 
elongation  is  more  frequent  at  an  earlier  period.  It  is  an  active  pro- 
cess of  growth.  The  cervix  elongates  in  continuation  of  a  process  of 
inflammation  and  engorgement,  aided  no  doubt  by  other  conditions, 
taking  their  rise  from  pregnancy  and  labor.  The  procidentia  uteri 
more  commonly  results  from  a  process  of  which  atrophy  of  the  uterus 
and  of  the  pelvic  padding  is  the  first  step,  and  superincumbent  pres- 
sure is  the  second.  This  is  more  frequently  observed  in  women  past 
the  climacteric ;  it  first  appears  at  this  period  ;  it  is  not  the  climax  of 
processes  begun  after  childbirth.  Indeed,  it  may  occur  in  women  who 
have  never  borne  children.     In  these  cases  the  uterus  is  sometimes  so 


560  PROLAPSUS    OF    THE    UTERUS. 

shrunken  that  it  is  scarcely  bigger  than  a  walnut,  and  there  is  commonly 
closure,  complete  or  partial,  of  the  os  uteri.  In  one  case  I  found 
atrophy  of  the  uterus  almost  absolute. 

S.  Cooper  has  cited  cases  of  complete  procidentia  of  the  gravid 
uterus.  I  have  seen  a  case  of  the  kind  in  the  practice  of  the  Royal 
Maternity  Charity.  In  this  condition  it  is  obvious  that  to  expel  the 
child  the  uterus  can  derive  no  help  from  the  diaphragm  or  abdominal 
muscles.  If  the  whole  mass  can  be  easily  returned  within  the  pelvis, 
this  will  be  the  better  course.  If  not,  it  will  be  wise  to  dilate  the 
cervix  uteri  artificially  by  means  of  my  water  dilators,  and  to  deliver 
by  forceps  or  turning,  taking  care  that  the  uterus  be  well  supported 
by  the  hands  of  an  assistant  during  the  delivery.  When  this  is  eifected, 
the  uterus  must  be  returned,  and  a  firm  perineal  bandage  be  applied 
to  prevent  it  from  falling  through  again.  Occasionally  procidentia  of 
the  gravid  uterus  is  simulated  by  pregnancy  with  hypertrophic  elonga- 
tion of  the  cervix.  When  labor  comes  on,  the  child  passes  along  the 
lengthened  canal  of  the  cervix,  and  is  arrested  at  the  os  externum 
uteri,  which  lies  outside  the  vulva.  The  os  externum  being  thus  enor- 
mously distended,  has  been  taken  for  the  uterus  itself,  the  body  of 
which  is  really  in  its  normal  position.  I  have  seen  several  examples 
of  this.  In  each  case  the  practitioner  summoning  me  assumed  it  to 
be  complete  procidentia.  I  am  therefore  inclined  to  doubt  whether 
some  of  the  cases  of  presumed  procidentia  of  the  gravid  uterus  recorded 
by  older  authors  were  not  in  reality  cases  of  hypertrophied  cervix. 

The  uterus,  in  a  state  of  prolapsus,  is  sometimes  affected  with  scir- 
rhus  and  cancer.  A  case  of  this  description  was  met  with  by  Ruysch  ; 
such  a  complication  was  seen  in  one  instance  by  Cruveilhier.  (Anat. 
Pathol.,  livr.  xvi.)  Its  extirpation  was  completed  by  MM.  Recamier 
and  Marjolin,  by  means  of  a  ligature,  though  the  patient  is  stated  to 
have  died  afterwards  from  some  cause  Avhich  had  nothing  to  do  with 
the  operation.  Instead  of  this  method,  which  must  inevitably  be  at- 
tended with  great  risk  of  tying  a  portion  of  the  bladder,  M.  Cruveil- 
hier recommends  making  an  incision  into  the  posterior  parietes  of  the 
vagina,  and  thus  getting  into  the  great  peritoneal  cul-de-sac  between 
the  bladder  and  rectum,  drawing  the  uterus  outward,  and  separating 
its  cellular  connections  to  the  bladder.  A  woman,  whose  uterus  was 
cancerous,  and  in  a  state  of  complete  prolapsus,  without  any  inversion, 
was  attended  by  Langenbeck,  who  succeeded  in  removing  the  diseased 
organ  with  a  knife,  and  the  patient  recovered.  According  to  this 
author's  description,  after  the  vagina  had  been  separated  from  the 
uterus,  the  latter  organ  was  detached  from  the  peritoneum  without 
opening  into  the  peritoneal  cavity,  a  small  portion  of  the  fundus  uteri 
being  left,  however,  apparently  quite  sound.  The  bleeding  was  very 
profuse,  and  required  the  use  of  the  needle  and  ligatures. 

The  Treatment  of  Prolapsus  and  ITi/jMrtrophy  of  the  Uterus. — The 
treatment  best  calculated  to  meet  the  early  stages  in  the  production  of 
these  conditions  has  been  described  in  preceding  chapters.  It  remains 
now  to  discuss  the  modes  of  dealing  with  the  more  advanced  or  con- 
firmed cases.  Keeping  the  uterus  at  its  proper  level  is  a  very  efiectual 
factor  in  curing  inflammation  and  hypertrophy  of  the  cervix.     This  is 


TREATMENT.  561 

due,  I  believe,  to  the  relief  which  the  vessels  supplying  the  organ  ob- 
tain when  supported  in  their  natural  relations.  When  the  cervix  is 
sunk  low  in  the  pelvis  the  vessels  are  dragged  down,  become  elongated, 
varicose,  they  form  large  loops,  with  a  depending  curve,  liable  to  angu- 
lation by  compression ;  the  circulation  through  them  is  necessarily 
sluggish,  and  seeks  relief  by  serous  effusions  into  the  tissues,  thus  in- 
creasing the  hypertrophy,  and  impeding  curative  processes.  A  consid- 
erable degree  of  oedema  is  a  frequent  complication  of  the  advanced  de- 
grees of  prolapsus,  with  inversion  of  the  vagina.  To  such  an  extent 
is  this  the  case  that  occasionally  the  bulk  of  the  protruding  mass  be- 
comes so  great  that  there  is  extreme  difficulty  in  returning  it  into  the 
pelvis.  To  facilitate  this  step  it  is  necessary  first  to  get  rid  of  the  oedema. 
This  is  done  by  applying  strips  of  plaster  around  the  mass,  so  as  to 
compress  and  support  the  tissues.  It  is  often  useful  to  prick  the  swollen 
tissues  with  a  lancet,  to  let  the  serum  drain  oflF.  After  two  or  three 
days,  the  patient  keeping  her  bed,  the  mass  will  commonly  be  so  far 
diminished  as  to  enable  it  to  return.  If  swelling  be  attended  by  in- 
flammation of  the  surface  of  the  mass,  it  will  be  proper  first  to  subdue 
this  by  cooling  astringent  lotions ;  lead  or  tannin  answers  well ;  or  it 
may  even  be  desirable  to  apply  leeches.  A  properly  applied  pessary 
acts  partly  by  rein  verting  the  vagina  and  cervix,  by  restoring  the  ves- 
sels to  their  natural  relations,  and  thus  by  opposing  two  of  the  most 
prominent  factors  in  the  production  of  prolapsus. 

Maintaining  the  uterus  at  its  proper  level  further  acts  by  taking  off' 
the  strain  upon  the  ligaments,  and  thus  giving  them  the  opportunity 
of  recovering  their  tone.  They  are  somewhat  elastic,  and  if  relieved 
of  the  drag  upon  them»they  slowly  retract,  and  in  time  regain  much — 
I  believe  rarely  all — of  their  pristine  value. 

Sometimes  the  procidentia  is  irreducible.  Inflammation  may  have 
been  followed  by  adhesions  which  bind  the  uterus  and  appendages 
down.  In  one  case  pain  was  so  much  increased,  and  so  obstinate  a 
constipation  came  on,  that  it  became  absolutely  necessary  to  let  the 
uterus  descend  again.  In  any  irreducible  case  we  must  be  content 
with  supporting  the  swelling,  and  preventing  its  increase  by  a  suspen- 
sory bandage,  and  drawing  off  the  urine  by  catheter,  whenever  requisite. 
Sometimes  the  displacement  of  the  bladder  causes  an  incontinence  of 
urine. 

The  extreme  pain  which  attends  the  attempt  to  return  the  proeident 
mass  into  the  pelvis  is  often  due  to  some  degree  of  inflammation  having 
been  set  up  in  the  peritoneum  lining  the  pouch  into  which  the  intes- 
tines descend,  at  the  upper  and  back  part  of  the  womb,  or  of  the  peri- 
toneal investment  of  the  intestines  themselves ;  and  death  may  in  these 
circumstances  take  place,  with  many  symptoms  of  the  same  kind  as 
attend  upon  fatal  strangulated  hernia,  or  ileus. 

Another  cause  of  the  bulk  of  the  tumor,  and  of  the  difficulty  in  re- 
placing it,  arises  from  the  presence  of  the  intestines  in  the  sac,  which 
seldom  reside  there  long  without  inflammation  of  their  peritoneal  coat 
being  set  up ;  not  of  so  acute  a  character  as  to  produce  formidable 
symptoms,  but  matting  their  diflFerent  coils  together,  and  tying  them 
firmly  to  the  interior  of  the  sac. 

36 


562  PROLAPSUS    OF    THE     UTERUS. 

These  considerations,  then,  suggest  that  reduction  should  be  tried 
very  gently,  closely  observing  any  resistance  that  may  be  presented  to 
the  return  or  retention  of  the  parts  within  the  pelvis. 

The  immediate  effect  of  returning  the  prolapsed  uterus  to  its  place 
is  to  shorten  the  elongated  neck,  if  the  case  be  one  of  hypertrophic 
elongation.  The  structure  is  elastic;  it  retracts  like  the  ligaments 
when  the  strain  is  taken  oflF.  But  much  is  not  gained  in  this  way; 
perhaps  nothing  in  extreme  senile  cases,  where  there  is  thinning  of  the 
cervix.  In  these  cases,  when  the  procident  mass  is  returned,  the  cervix 
being  too  long  for  the  space  in  the  pelvis  which  has  to  receive  it,  it  is 
doubled  up.  But  the  plan  of  reduction  and  supporting  the  mass  inside 
the  pelvis  by  mechanical  means  is  not  so  irrational  as  it  is  by  some 
thought  to  be.  Certainly  it  is  not  a  cure;  it  is  a  palliative  proceeding. 
But  this  indication  is  often  fairly  fulfilled.  I  could  exhibit  a  consid- 
erable number  of  hospital  patients  who  by  help  of  a  stem-pessary  are 
placed  in  comparative  comfort,  and  are  enabled  to  earn  their  livelihood 
by  washing  and  other  laborious  occupations. 

The  keeping  the  uterus  within  the  pelvis  at  its  proper  height  is 
further  an  important  condition  preparatory  to  any  of  the  various  ope- 
rations performed  upon  the  vagina  and  cervix.  By  this  means,  aided 
by  rest  in  the  recumbent  posture,  the  uterine  supports  regain  strength ; 
and  this  will  be  of  essential  service  when  the  patient  recovers  from  the 
operation.  A  troublesome  consequence  of  prolapsus  is  the  "spasm" 
or  reflex  irritation,  caused  by  the  presence  of  the  uterus  near  the  vulva. 
This  distress  is  pretty  sure  to  be  removed  by  a  Hodge's  or  other  suitable 
pessary  carrying  the  uterus  up  to  its  proper  level. 

Whatever  other  treatment  be  adopted,  it  is  a'point  of  great  impor- 
tance to  keep  the  bladder  periodically  relieved.  For  want  of  attention 
to  this  the  pouch  formed  at  the  lower  part  of  the  bladder,  by  the  drag- 
ging down  of  the  cervix  uteri,  tends  to  get  bigger,  and  becomes  an 
aggravation  of  the  uterine  and  vaginal  displacement.  To  empty  the 
bladder  fully  it  is  necessary  that  the  protruding  mass  should  be  re- 
turned into  the  pelvis.  Some  women  afflicted  with  procidentia  have 
learned  the  trick  of  pressing  the  anterior  part  of  the  mass  upwards  by 
the  hand  during  micturition,  and  thus  of  empyting  the  bladder  more 
completely.  The  collection  of  phosphatic  deposits,  and  the  formation 
of  calculi  may  thus  be  prevented. 

3fode  of  Returning  the  Procident  Mass. 

The  patient  should  lie  in  the  semi-prone  posture,  as  this  greatly 
facilitates  the  entry  of  the  procident  mass.  The  tumor  should  be 
treated  as  a  hernia ;  the  part  last  emerging  should  be  returned  first. 
The  base  should  be  grasped  by  the  two  hands,  and  gentle  pressure  ex- 
erted at  a  part  of  its  circumference  at  a  time,  whilst  the  mass  is  being 
pushed  back  in  the  direction  of  the  axis  of  the  pelvis. 

When  the  parts  have  been  reduced  we  have  to  consider  how  to  keep 
them  in  position.  Dr.  McClintock  very  properly  insists  upon  the  ex- 
[)ediency  of  keeping  the  patient  in  bed,  keeping  the  bowels  soluble, 
and  using  an  astringent  lotion  twice  a  day,  as  a  preparation  for  the  use 


TREATMENT PESSARIES.  563 

of  a  pessary.  Under  these  precautions  any  inflammation  or  ulceration 
of  the  uterus  or  vagina  soon  heals,  and  the  mucous  membrane  recovers 
its  normal  moisture.  The  vulva  also  regains  some  portion  of  its  natu- 
ral firmness,  and  becomes  better  able  to  retain  a  pessary. 

It  must  not,  however,  be  concluded  that  mechanical  treatment  is 
everything.  It  is  always  indeed  useful,  but  sometimes  it  is  not  the 
most  important  part  of  the  treatment.  An  essential  point  to  consider 
is  the  complications,  as  hypertrophy,  inflammation,  or  engorgement. 
In  many  cases  the  prolapsus  disappears  when  the  uterus  is  restored  to 
health.  In  carrying  out  the  cure  of  the  inflammatory  complications 
mechanical  support  is  often  of  signal  service. 

In  a  consiclerable  number  of  the  slighter  forms  of  prolapsus  much 
benefit  is  obtained  from  the  frequent  use  of  astringent  injections.  And 
nothing  more  conclusively  proves  the  value  of  the  vagina  in  support- 
ing the  uterus  than  the  action  of  astringents  upon  it.  The  corrugation 
and  contraction  of  the  canal  which  these  induce  is  often  found  sufiicient 
to  keep  the  uterus  in  place  so  long  as  the  effect  upon  the  vagina  lasts. 
An  eflectual  and  convenient  way  of  applying  astringents  for  this  pur- 
pose is  to  wrap  up  a  scruple  of  alum  or  sulphate  of  zinc  in  powder,  in 
a  piece  of  cotton- wool,  and  to  insert  this  in  the  vagina.  This  the 
patient  can  commonly  do  with  her  fingers ;'  but  where  this  is  difficult 
it  is  easily  accomplished  by  aid  of  the  plug  speculum  I  contrived  for 
the  purpose. 

The  Use  of  Pessaries. 

It  is  one  of  the  many  controverted  points  in  gynsecology  whether 
the  use  of  pessaries  in  prolapsus  is  or  is  not  a  scientific  proceeding.  If 
pessaries  are  found  useful,  it  matters  little  whether  they  satisfy  the 
conditions  of  science.  That  thousands  of  women  do  find  comfort  and 
benefit  from  their  use  is  a  fact  too  notorious  to  be  disputed.  Still  it  is 
asserted  that  their  usefulness  being  only  palliative  and  temporary,  and 
science  supplying  modes  of  treatment  which  are  curative,  pessaries 
should  be  discarded.  If  the  premises  ^vere  true  we  could  not  reject 
the  conclusion.  But  they  are  only  partially  true;  and  a  wide  field  is 
still  left  for  study  and  the  application  of  various  modes  of  treatment, 
according  to  the  various  forms  of  the  malady.  In  the  first  place,  I 
add  my  testimony  to  that  of  Dr.  West,  Dr.  McClintock,  and  many 
others  who  have  seen  not  only  comfort,  but  cure  result  from  pessaries. 

In  the  second  place,  the  operations  to  which  alone  the  claim  to  be 
scientific  is  arrogated,  howsoever  well  devised,  are  not  certain  in  their 
results;  they  are  not  free  from  the  dangers  which  attend  other  similar 
operations ;  and  they  not  seldom  fail  in  their  intent.  No  doubt  these 
operations  may  be,  and  will  be,  improved,  and  become  more  certainly 
successful.  But,  in  the  meantime,  it  is  not  wise  to  discard  instruments 
so  useful  as  pessaries. 

As  prolapsus  is  a  hernia,  so  a  pessary  is  a  truss.  Mr,  John  Wood 
and  other  surgeons  have  devised,  and  successfully  executed,  admirable 
operations  for  the  radical  cure  of  inguinal  hernia.  These  have  not, 
however,  supplanted  trusses.     So  it  is  with  prolapsus.     Notwithstand- 


664  PROLAPSUS    OF    THE    UTERUS. 

ing  the  ingenuity  and  success  of  several  of  the  operations  for  its  radi- 
cal cure,  pessaries  are  still  found  necessary. 

Before  applying  pessaries  it  is  necessary  to  ascertain  the  absence  of 
adhesions  binding  down  the  uterus.  This  is  done  by  careful  manipu- 
lation, and  by  the  use  of  the  sound.  On  carrying  the  uterus  gently 
upwards  obstruction,  if  existing,  will  be  felt.  Occasionally' the  part 
is  returned,  after  a  great  deal  of  trouble;  but,  owing  to  the  long-altered 
state  of  the  parts,  the  reduction  brings  on  worse  symptoms  than  re- 
sulted from  the  procidentia. 

Deseription  of  Pessaries. 

The  word  pessary  comes  from  niffcrcu,  to  soften,  and  was  originally 
used  to  signify  a  soluble  medicinal  substance,  similar  to  a  suppository. 
It  is  only  by  a  corruption  that  it  has  come  to  be  applied  to  the  instru- 
ments designed  to  support  the  uterus.  To  these  instruments  it  has 
recently  been  proposed  to  give  the  more  appropriate  name  "hystero- 
phores,"  from  varipa,  womb,  and  ^epiu),  I  bear. 

Pessaries,  that  is,  hysterophores,  act  on  different  principles.  The 
object  of  most  is  to  counteract  prolapsus,  or  to  keep  the  Avomb  in  proper 
form  and  place.  Others  are  designed  to  stimulate  development  and 
function.     Others  to  subdue  inflammation  and  irritation  of  the  vagina. 

Those  which  have  the  first  object  in  view  act  on  one  or  more  of  the 
following  principles : 

1.  By  mere  distension  of  the  vagina  below  the  uterus  they  block  up 
the  outlet,  and  so  keep  the  uterus  from  falling  out.  The  balls  and  air- 
pessaries  mostly  act  in  this  way. 

2.  Others  act  by  utilizing  the  contractile  power  of  the  vagina.  The 
stem-and-cup  pessaries  act  in  this  way,  combining  something  of  the 
leverage  power  of  the  next  class. 

3.  A  third  class  act  by  leverage  principally,  thus  utilizing  the  nor- 
mal act  of  respiration  and  the  contractile  property  of  the  vagina  as 
well. 

4.  A  fourth  class  act  by  directly  supporting  the  uterus  or  its  axis 
of  suspension  by  a  disk  which  bears  up  the  uterus,  and  is  itself  sup- 
ported by  a  wire-stem,  having  a  bearing  on  the  pubes 

Fig.  117.  outside. 

5.  A  fifth  class  are  intra-uterine.     These  may  be 
subdivided  into  two  orders. 

A.  Those  designed  to  straighten  the  uterus  when 
flexed.  These  are  of  two  kinds :  those  which 
are  attached  to  extra-uterine  sujDports,  and 
those  which  are  simple. 

B.  Those  designed  to  stimulate  development  and 
function,  as  the  galvanic. 

6.  A  sixth  class  are  vaginal  pessaries,  designed  to 

The  galvanic  pessary,  overcome  irritability   and   inflammation,  by   keeping 
a, zinc;  6, copper,     the  walls  apart  and  at  rest — "vaginal  rests." 

An  attempt  to  give  anything  approaching  to  a  com- 
plete account  of  the  pessaries  that  have  been  contrived  would  be  hope- 


PESSARIES.  565 

less.  Dr.  A.  K.  Gardner  gives  drawings  of  123  different  forms ;  and 
he  is  far  from  exhaustive.  Almost  all  fall  within  one  or  other  of  the 
classes  indicated  above.  Most,  especially  of  those  of  the  first  and  fourth 
classes,  may  be  discarded  as  vicious  in  principle  and  faulty  in  practice; 
and  a  judicious  selection  from  the  most  approved  specimens  of  the  other 
classes  will  bring  the  really  useful  instruments  down  to  a  very  small 
number. 

The  Choice  of  Pessaries,  and  the  Mode  of  ajjplying  them. 

In  one  class  of  cases,  chiefly  of  simple  prolapsus,  we  can  avail  our- 
selves of  the  contractile  property  of  the  vagina.  In  another  class,  we 
can  derive  no  assistance  from  this  source.  We  must  apply  all  the  sup- 
port.    These  conditions  govern  the  choice  of  pessaries. 

The  first  class  of  cases  includes  those  where  there  is  prolapsus,  not 
procidentia,  where  it  is  comparatively  recent,  and  the  patient  is  not 
past  the  climacteric.  For  many  of  these  cases,  especially  if  there  is 
any  inflammatory  complication,  and  the  patient's  circumstances  forbid 
her  to  rest,  some  modification  of  Hodge's  pessary  is  the  best.  Since,  in 
the  cases  under  consideration,  it  is  assumed  that  the  vagina  preserves 
contractility,  our  study  should  be  not  to  destroy  or  diminish  this  prop- 
erty, but  to  utilize  it.  Hence  w^e  must  reject  the  whole  array  of  box- 
wood balls,  and  huge  thick  rings,  which  depend  for  their  efficacy  upon 
mere  bulk,  A  globe  of  moderate  size  will  not  do,  because  it  Avill  in 
all  probability  be  soon  expelled.  To  be  retained,  it  must  be  large 
enough  to  cause  some  difficulty  in  getting  it  in  through  the  vulva,  it 
must  then  take  a  bearing  upon  the  floor  of  the  pelvis,  resting  upon  the 
ischiatic  tuberosities  and  sacro-sciatic  ligaments.  Thus  placed  in  the 
way  the  uterus  cannot  escape.  But  the  penalty  is  the  destruction  of 
the  contractility  of  the  vagina  by  constant  distension,  and  often  serious 
inflammation  and  ulceration  of  its  walls.  Offensive  discharges  of  mu- 
cus, pus,  and  blood  follow ;  and  pain  compels  the  patient  to  seek  relief. 
Under  these  circumstances  the  removal  of  the  pessary  is  sometimes  a 
task  of  difficulty,  particularly  if  the  ball  is  of  large  diameter.  When 
such  a  ball  has  been  worn  for  some  years,  the  vulva  will  be  found  so 
much  contracted  that  it  represents  a  ring,  whose  diameter  is  much  less 
than  that  of  the  pessary.  The  vulva  by  age  and  abandonment  of  use 
may  have,  moreover,  become  extremely  rigid. 

The  extraction  of  a  ball-pessary  under  these  circumstances  resembles 
the  delivery  of  a  child  whose  head  is  impacted,  with  this  difference, 
that  the  bail,  although  smaller,  is  absolutely  unyielding.  Sometimes 
the  ball  may  be  hooked  out  with  the  fingers  by  getting  the  last  joint 
fairly  above  it  and  pressing  it  down  upon  the  perineum.  But  this  is 
often  difficult;  the  ball  rolls  over  and  cannot  be  fixed.  It  must  be 
seized  with  forceps.  A  small  midwifery-forceps  will  perhaps  answer 
the  purpose,  but  the  extreme  rigidity  of  the  vulva  may  prevent  the 
introduction  of  the  blades,  unless  the  margin  be  first  incised.  It  is 
better  to  do  this  than  to  use  violence.  To  grasp  the  ball,  whatever 
forceps  is  used,  thg  ends  must  be  curved  so  as  to  get  beyond  the  equa- 
tor, otherwise  they  will  not  hold.     In  one  very  difficult  case  that  came 


bQQ  PROLAPSUS    OF    THE    UTERUS. 

under  my  care  at  the  London  Hospital,  I  got  a  long  and  strong  poly- 
pus-forceps curved  at  the  ends  so  that  it  held  well.  The  ball  was 
nearly  as  large  as  the  head  of  a  seven  months'  child. 

There  are  still  to  be  found  in  the  instrument-makers'  shops  huge 
rings  or  disks  made  of  india-rubber  or  boxwood,  or  other  material, 
which  also  act  by  bulk  and  by  blocking  up  the  pelvic  outlet.  The 
surgeon  now  and  then  becomes  acquainted  with  them  through  the  mis- 
haps they  occasion.  Like  the  balls  they  set  up  vaginitis,  ulceration, 
and  cases  are  not  rare  in  which  even  perforation  has  ensued,  and  the 
pessary  has  made  its  way  wholly  or  in  part  into  the  bladder  or  rectum. 
The  vaginal-portion  also  received  into  the  ring,  has  become  swollen, 
inflamed,  and  incarcerated. 

Liiders^  relates  a  case  of  a  lady  who  had  a  pessary  applied  by  a  mid- 
wife, of  caoutchouc  stuffed  with  hair,  3J  inches  long,  2J  inches  broad, 
and  1  inch  thick.  Peritonitis  followed,  and  then  hectic.  A  swelling 
was  felt  between  the  vagina  and  rectum ;  the  pessary  was  not  found. 
A  year  later  another  physician  found  the  same  swelling ;  and  a  trans- 
verse scar  in  the  posterior  vaginal  wall.  Two  years  later  a  fistulous 
opening  appeared  in  the  anterior  wall  of  the  rectum,  which  enlarged, 
and  at  last  the  pessary  was  removed.  The  patient  then  recovered 
rapidly.     The  pesssary  had  first  passed  into  Douglas's  pouch. 

Where  resort  is  deemed  necessary  to  the  principle  of  filling  the 
pelvis  below  the  uterus,  the  best  of  all  means  is  the  air-pessary  con- 
trived by  Gariel.  This  consists  of  a  globe  of  india-rubber  prepared 
so  as  to  resist  moisture,  and  which  can  be  distended  after  it  is  intro- 
duced into  the  vagina.  The  patient  can  apply  and  remove  it  herself; 
and  removal  is  easy  by  letting  the  pessary  collapse. 

Some  more  m-odern  forms  of  pessary  are  not  free  from  objection. 
Zwanck's  instrument  is,  in  my  opinion,  one  of  these.  It  had,  and  may 
still  have,  under  various  modifications,  considerable  vogue  on  the  Con- 
tinent, and  a  few  years  ago  it  was  much  used  in  London.  It  does  not, 
indeed,  act  like  the  ball  by  blocking  the  lower  cavity  of  the  pelvis; 
but  it  depends  greatly  for  its  efficacy  upon  stretching  out  the  upper 
part  of  the  vagina.  The  wings,  when  expanded  in  situ,  present  mar- 
gins narrow  enough  to  bury  themselves  in  a  ring  which  they  form  in 
the  vagina ;  after  a  time  the  vagina  contracts  below  this  ring,  and  the 
pessary  is  incarcerated ;  then  there  is  great  danger  of  ulcerative  perfo- 
ration. I  have  experienced  considerable  difficulty  in  extracting  the 
instrument  under  these  circumstances.  I  do  not  say  that  these  acci- 
dents are  common,  but  considering  the  frequent  carelessness  of  the  class 
of  women  who  use  pessaries,  we  ought  not  to  use  instruments  which 
often  require  medical  observation.  It  is  right,  however,  to  add  that 
Zwanck's  instrument,  including  its  modifications,  is  still  very  highly 
estimated  by  many  excellent  observers.  Dr.  West,  in  particular,  says, 
when  deprecating  the  resort  to  the  various  surgical  proceedings  for  the 
cure  of  prolapsus,^  "  I  may  add  that  during  the  last  three  years  of  my 

1  Monatsschiift  fiir  Geburtskunde,  1858. 

^  Diseases  of  Women,  3d  edition,  1864,  p.  182. 


PESSARIES.  567 

connection  with  St.  Bartholomew's  Hospital,  I  did  not  meet  with  a 
single  case  of  prolapsus  which  a  Zwanck's  pessary  failed  to  retain." 

August  Mayer^  also  extols  the  instrument  as  effectual  in  all  cases, 
and  as  obviating  all  necessity  for  perinseoraphy.  He  admits,  however, 
that  it  sometimes  causes  ulceration  of  the  vaginal  walls ;  and  says  that 
he  and  his  father,  C.  Mayer,  frequently  practiced  amputation  of  one 
or  both  lips  of  the  cervix  with  the  best  results. 

The  Hodge  or  lever-pessary  answers  most  of  the  indications  with 
the  least  amount  of  drawbacks.  It  is  of  essential  importance  to  bear 
in  mind  what  is  too  often  forgotten — namely,  that  it  is  a  lever,  A  lever 
must  be  freely  movable.  The  lever-jjessary,  to  act  properly  and 
safely,  must  float  in  the  pelvis.  It  is  simply  held  in  the  vagina.  It 
should  not  take  any  bearing  upon  the  walls  of  the  pelvis  ;  to  make  it 
do  this  would  be  to  degrade  it  to  the  level  of  the  old  ring  pessaries, 
and  to  sacrifice  its  principle  of  action.  This  is  what  happens  if  too 
large  an  instrument  is  used.  Then  the  vagina  will  be  put  on  the 
stretch,  its  elasticity  will  be  impaired,  leverage  is  lost,  and  tlie  jDcssary 
pressing  unduly  may  cause  inflammation  and  ulceration. 

Let  us  apply  a  lever  to  a  case  of  prolapsus,  with  engorgement  of  the 
vaginal-portion.  This  can  be  done  with  safety,  because  the  pessary 
does  not,  like  Zwanck's  or  many  others,  touch  the  os  uteri.  We  select 
one  moulded  to  the  form  of  the  vagina — that  is,  when  viewed  laterally, 
of  a  sigmoid  shape.  The  size  may  be  determined  approximately  by 
the  measurement  taken  of  the  vagina  by  the  finger.  The  length 
should  be  such  that  whilst  the  upper  limb  will  rise  into  the  vaginal 
duplicature  behind  the  cervix  uteri,  the  lower  limb  will  sit  behind  the 
symphysis  pubis  well  above  the  meatus  urinarius.  If  it  project  below 
this,  it  will  be  troublesome,  and  be  liable  to  expulsion.  Its  breadth 
should  be  such  as  not  to  stretch  the  vagina. 

The  mode  of  action  is  as  follows :  During  inspiration  or  exertion, 
the  intestines  driven  down  upon  the  uterus  and  bladder  cause  the 
anterior  wall  of  the  vagina  to  descend.  The  lower  limb  of  the  pessary 
being  applied  to  this  wall  is  carried  down  wath  it,  and  the  upper  limb 
necessarily  rises  in  the  opposite  direction,  lifting  the  roof  of  the  vagina 
and  the  uterus,  and  keeping  the  fundus  of  the  uterus  inclined  forwards. 
So  long  as  the  body  of  the  uterus  is  maintained  in  anteversion,  it  can 
hardly  suffer  prolapsus.  The  leverage  action  of  the  pessary  is  also 
greatly  aided  by  the  posterior  wall  and  floor  of  the  vagina.  This  at 
the  lower  part  forms  a  thick  elastic  and  muscular  structure,  which, 
partly  by  its  contractile  property,  and  partly  under  atmospheric  pres- 
sure, is  normally  kept  in  close  apposition  to  the  anterior  wall,  giving  it 
material  support,  and  thus  constituting  one  of  the  greatest  impediments 
to  prolapsus.  The  pressure  so  exerted  of  course  will  bear  upon  the 
upper  limb  of  the  pessary,  which  is  embraced  in  the  vagina.  The 
sphincteric  action  of  the  vulva  also  comes  in  aid.  This,  contracting 
the  outlet,  helps  to  support  the  instrument  above  it.  The  instrument 
is  figured  under  the  treatment  of  "  Retroversion." 

The  instrument  should  be  worn  continuously.     It  is  not  necessary 

^  Monatsschrift  fur  Geburtskunde,  1858. 


568  PROLAPSUS    OF    THE    UTEEUS. 

to  remove  it  at  night.  It  does  not  prohibit  intercourse,  although  it 
would  be  better  that  this  should  be  avoided.  Conception  has  often 
take  place  whilst  it  was  being  worn.  As  it  requires  accurate  adaptation, 
the  patient  or  a  nurse  cannot  always  be  trusted  to  remove  or  replace  it. 
But  by  help  of  diagrams  and  direct  demonstration  this  may  be  accom- 
plished. I  have  several  patients  who  manage  the  instrument  with 
perfect  precision. 

After  a  time — several  weeks,  or  perhaps  months — the  uterus  having 
been  kept  in  position,  the  vaginal-portion  being  prevented  from  chafing 
against  the  lower  part  of  the  vagina,  engorgement  will  have  subsided, 
and  the  supports  of  the  uterus  will  have  recovered  tone. 

In  many  cases,  under  proper  adjuvant  treatment,  such  as  the  use  of 
local  astringents  and  general  tonics,  a  cure  is  effected.  The  uterus  is 
sustained  by  its  natural  supports.  If  this  favorable  result  is  not  more 
frequent,  it  is  because  so  many  interfering  conditions  occur. 

It  should  be  enforced  as  an  imperative  rule  that  women  wearing  this 
or  any  other  pessary  should  have  it  removed  at  fixed  intervals,  to  avoid 
mischief,  and  to  observe  the  condition  of  the  parts. 

The  manoeuvres  for  introducing  the  lever-pessary  are  described 
under  "  Retroflexion." 

Some  modifications  of  Hodge's  pessary,  designed  to  meet  special  cases, 
or  to  obviate  special  inconveniences,  have  been  designed.  One  of  Pro- 
fessor Hodge's  original  forms  was  that  of  the  letter  U,  the  legs  being 
curved.  The  two  ends  being  applied  behind  the  symphysis  have  been 
found  to  dig  holes  into  the  bladder.  No  doubt  a  great  gain  was  effected 
when  these  pointed  ends  were  got  rid  of,  by  completing  the  ring.  But 
this  entailed  the  occasional  inconvenience  of  pressing  upon  the  urethra, 
and  the  rigid  transverse  bar  also  caused  distressing  friction.  To  dimin- 
ish this  Dr.  Greenhalgh  united  the  horns  by  an  elastic  band.  This  is 
a  real  improvement  in  some  cases.  But  in  the  great  majority  of  cases 
it  is  not  necessary.  I  have  generally  found  it  possible  to  obviate  all 
trouble  by  widening  the  lower  arch — that  is,  by  making  the  transverse 
portion  a  little  straighter.  This  completion  of  the  ring  by  adding  the 
transverse  portion,  increases  the  leverage  power,  since  it  is  the  central 
portion  of  the  vagina  that  descends  most. 

If  there  be  marked  vaginal  cystocele  or  rectocele,  with  large  yielding 
vulva,  it  will  be  difficult  or  impossible  to  get  a  Hodge  to  act.  It  will 
generally  fall  out,  and  even  if  it  keep  in,  the  conditions  upon  which  its 
leverage  action  depend  are  so  feeble,  that  we  must  turn  to  other  means. 

When  the  Hodge  fails,  we  have  often  a  valuable  resource  in  other 
forms  of  pessary,  which  act  upon  somewhat  different  principles.  The 
next  form  to  try  is  the  stem-and-cup  pessary.  To  a  certain  extent, 
this,  I  believe,  also  acts  upon  the  principle  of  a  lever,  but  it  does  not 
depend  entirely  upon  it.  Here,  as  in  the  case  of  the  lever,  it  is  im- 
portant to  select  an  instrument  as  small  as  will  answer  the  purpose. 
It  consists  of  an  upper  expanded  portion,  the  cup  or  corolla,  which 
receives  the  vaginal-portion,  and  a  somewhat  tapering  cylinder,  curved 
to  correspond  with  the  pelvic  or  vaginal  curve.  It  is  likened  to  a  horn. 
The  whole  is  hollow,  for  the  escape  of  discharges. 

Now,  the  bare  instrument  in  this  form  will,  under  favorable  circum- 


PESSARIES. 


569 


Fig.  lis. 


stances,  maintain  itself  mi  situ,  and  act  curatively.  The  study  of  them 
will  best  explain  upon  what  principles  the  instrument  acts.  When  the 
instrument  is  in  situ,  the  vaginal-portion  resting  on  the  corolla,  the 
narrow  stem  is  grasped  by  the  vagina,  which  contracts  upon  it.  As 
the  instrument  represents  a  cone,  of  which  the  apex  is  directed  down- 
wards, a  force  grasping  it  necessarily  carries  the  cone  upwards,  and  the 
uterus  rises  with  it.  Then  the  cone,  by  its  length,  is  also  a  lever,  and 
is  subject  to  exactly  the  same  influences  as  Hodge's  lever  pessary. 
That  the  instrument  acts  in  this  way  is  proved  by  the  facts  that  in 
suitable  cases  when  the  vagina  is  contractile,  the  pessary  is  self-retain- 
ing, and  that  in  many  cases  it  ends  by  curing  the  prolapsus. 

In  other  cases,  where  the  power  of  the  vagina  is  insufficient  to  grasp 
the  stem,  its  retention  is  aided  by  external  elastic  bands  M'hich  are  car- 
ried up  in  front  and  behind,  and  attached  to  an  abdominal  belt.  The 
elastic  bands,  yielding  at  every  inspiration,  permit  the  natural  ascent 
and  descent  of  the  uterus,  and  obviate  the  concussion  and  violence 
which  rigid  external  supports  would  cause.  The  material  of  these  pes- 
saries should  be  vulcanite. 

The  introduction  is  not  difficult.  A  finger  of  the  left  hand  is  intro- 
duced into  the  vagina,  and  presses  back  the  perineum;  the  corolla  of 
the  pessary  held  in  the  right  hand  is  slipped  by  its 
edge  beneath  the  guiding  finger,  and  in  front  of  the 
fourchette,  being  made  to  press  backwards,  so  as  to 
make  its  way  in  by  expanding  the  perineum.  The 
direction  given  is  towards  the  hollow  of  the  sacrum, 
and  away  from  the  symphysis  pubis. 

If  the  vagina  be  very  much  relaxed,  if  there  be 
any  considerable  amount  of  rectocele  and  cystocele, 
the  corolla  must  be  proportionately  large,  or  the 
folds  of  the  vagina  will  bag  over  the  corolla,  and 
drag  the  uterus  down  by  the  side  of  it. 

When  there  is  no  vaginal  contractility,  there  is 
nothing  but  the  external  elastic  bauds  to  depend 
upon  to  keep  the  pessary  in  situ.  But  even  under 
these  circumstances  it  is  still  a  very  useful  instru- 
ment. This  is  the  case  in  prolapsus  and  procidentia 
of  aged  women.  When  the  functions  of  ovulation 
and  pregnancy  are  at  an  end,  the  uterus  undergoes 
atrophy,  losing  bulk,  increasing  in  hardness.  At 
the  same  time,  the  cellular  tissue  of  the  pelvis  loses 
much  of  its  fat;  the  vessels,  having  less  call  upon  them  for  supplies, 
bring  less  blood.  The  vagina,  too,  partakes  in  the  atrophic  process. 
The  general  result  is  a  small  uterus  imbedded  in  shrunKen  tissues. 
The  padding  is  gone,  the  uterus  falls.  Especially  is  this  the  case  if 
the  woman  leads  a  laborious  life.  Under  great  exertion  in  the  stand- 
ing or  kneeling  postures,  the  ill-supported  uterus  easily  falls  through 
the  pelvis.  Hence,  the  prolapsus  and  procidentia  of  senility  being 
mainly  the  consequence  of  atrophy,  nothing  short  of  mechanical  sup- 
port will  avail. 

Another  class  of  pessaries  act  upon  the  principle  of  directly  support- 


The  cup-aDd-stem 
pessary. 


570  PROLAPSUS    OF    THE    UTERUS. 

ing  the  anterior  wall  of  the  vagina.  If  this  is  kept  up,  as  we  have 
seen,  the  uterus  is  kept  up  with  it.  The  essential  constituents  of  all 
these  are :  first,  a  disk  of  suitable  shape  which  is  adapted  to  the  ante- 
rior wall  of  the  vagina  at  the  junction  of  its  roof  with  the  vaginal- 
portion  ;  secondly,  an  elastic  wire  which  supports  the  disk,  and  which 
is  carried  out  of  the  vulva  and  curved  up  in  front,  to  be  connected 
with  a  pad  which  is  secured  by  a  spring  or  bandage  against  the  sym- 
physis pubis.  Professor  Martin  uses  one  which,  instead  of  a  disk 
taking  its  bearing  upon  the  anterior  vaginal  wall,  has  a  ring-disk 
which  receives  the  vaginal -portion.  Dr.  Whitehead,  of  Manchester, 
uses  one  constructed  on  this  principle,  which  is  very  effective.  Dr. 
Gibson,  of  Newcastle,  in  an  excellent  practical  memoir^  on  "Prociden- 
tia Uteri,"  describes  a  truss  adapted  to  support  the  vulva. 

Where  internal  pessaries  cannot  be  borne,  or  do  not  answer,  many 
patients  find  relief  in  wearing  a  firm  perineal  pad,  attached  by  straps 
before  and  behind  to  an  abdominal  belt.  This  contrivance  is  a  kind 
of  artificial  perineum.  The  pad  strengthens  the  floor  of  the  pelvis, 
and  its  pressure,  by  keeping  up  the  posterior  wall  of  the  vagina  in 
contact  with  the  anterior  wall,  prevents  the  uterus  from  descending. 

Before  the  introduction  of  Zwanck's  and  Hodge's  pessaries,  the  use 
of  external  supports  was  much  more  frequent  than  it  is  now.  But  we 
should  not  lose  sight  of  what  has  often  proved  a  valuable  remedy. 
Hull's  utero-abdominal  supporter  is  the  best  known ;  and  one  known 
as  Dr.  Ashburner's  is  highly  commended  by  Dr.  West  and  others.  I 
have  seen  many  cases  in  Avhich  one  of  these  appliances  answered  the 
indications  of  keeping  the  uterus  inside  the  pelvis,  and  of  enabling  the 
patient  to  get  about,  and  even  to  go  through  severe  work  with  com- 
parative comfort.  "  Each  of  these  instruments  tightly  embraces  the 
hips.  Hull's  is  furnished  with  a  large  padded  metallic  plate,  fitted 
over  the  pubes,  and  Ashburner's  is  fitted  with  a  similar  plate  fitted  over 
the  sacrum.  The  chief  utility  of  these  metallic  plates  is  that  by  their 
firm  yet  gentle  counter-pressure  they  relieve  the  sympathetic  pains 
referred  to  the  back  in  one  case,  or  the  dragging  and  distress  in  the 
region  of  the  ovaries  in  the  other.  To  both  of  them  a  strap  passing 
between  the  legs,  with  a  perineal  pad,  is  adapted,  and  though  it  can  be 
dispensed  with  at  pleasure,  will  be  found  of  great  service  in  all  cases 
of  considerable  relaxation  of  the  vagina,  with  disposition  to  actual 
procidentia,  when  used  either  alone  or  in  combination  with  some  form 
of  internal  support."     (West.) 

The  strap  and  perineal  pad  have,  indeed,  the  disadvantage  of  heat- 
ing the  parts,  and  of  keeping  up  leucorrhoeal  discharge;  and  I  have 
even  known  them  to  cause  hypertrophy  of  the  labia  vulvae. 

In  all  the  contrivances  we  have  as  yet  discussed,  the  support  is  given 
below  the  uterus,  and  they  are  designed  to  meet  the  uterus,  and  to  resist 
its  fall.  But  whilst  adapting  these  often  indispensable  aids,  we  should 
not  forget  that  we  may  often  do  ranch  to  take  ofl"  the  superincumbent 
pressure  which  is  the  active  factor  in  producing  and  maintaining  the 


British  Medical  Journal,  1869. 


SURGICAL     OPERATIONS.  571 

prolapsus.  A  well-adjusted  abdominal  belt  will  do  this  ;  and  patients 
often  experience  considerable  relief  from  this  contrivance  alone. 

Some  form  of  internal  support  may  often  be  usefully  combined  with 
the  abdominal  belt. 

But  we  should  not  confine  our  attention  too  exclusively  to  mechanical 
means.  Portal  congestion,  hsemorrhoids,  dilatation  of  the  rectum,  and 
retrograde  disorder  of  the  digestive  system,  so  frequently  accompany 
prolapsus,  and  so  surely  aggravate  its  consequences,  that  special  atten- 
tion should  be  directed  to  mitigate  these  conditions.  Alteratives,  such 
as  mercury  or  podophyllin,  chloride  of  ammonium,  and  tonics,  as 
strychnia,  quinine,  and  iron,  will  often  be  of  singular  service.  We  must 
act,  in  short,  on  the  general  principle  of  removing  or  mitigating  all 
intercurrent  or  associated  morbid  complications.  Amongst  the  most 
common  are  the  climacteric  affections,  which  have  already  been  dis- 
cussed. 

Where  artificial  mechanical  support  adapted  internally  or  externally 
is  excluded,  or  where,  for  other  reason.s,  a  radical  cure  is  indicated, 
several  surgical  proceedings  are  available.  The  several  operations  are 
based  upon  different  principles,  arising  out  of  the  different  views  enter- 
tained as  to  the  causes  of  prolapsus. 

The  first  attempts  at  a  radical  cure  were  based  upon  the  simple  idea 
of  closing  the  vagina  or  vulva.  The  following  historical  account  is 
taken  from  S.  Cooper's  "  Surgical  Dictionary  :" 

"  The  late  Dr.  Hamilton  formerly  suggested  the  propriety  of  endeav- 
oring to  relieve  very  bad  and  confirmed  cases  of  prolapsus  uteri,  by 
exciting  adhesive  inflammation  in  the  vagina,  so  as  to  bring  about  an 
agglutination  of  its  surfaces.  However,  notwithstanding  the  more  or 
less  partial  closure  of  the  vagina,  occasionally  met  with  in  the  practice 
of  surgery  and  midwifery,  every  pathologist  is  aware  of  the  difficulty 
of  making  a  mucous  tissue  undergo  the  adhesive  inflammation  ;  and 
this  consideration  led  Dr.  Hamilton  not  to  attempt  it.  A  more  valua- 
ble and  practicable  operation  is  that  of  treating  such  cases  by  approxi- 
mating the  pared  surfaces  of  the  labia,  and  uniting  them  by  suture. 
Dr.  Ireland  tried  this  method  in  Dublin,  and  has  published  an  account 
of  the  success  which  attended  it.  (See  Dublin  Journ.  of  Med.  Science, 
vol.  vi,  p.  484.)  Cruveilhier  prefers  to  this  proposal  the  plan  of 
bringing  about  a  contraction  of  the  upper  part  of  the  vagina,  by  touch- 
ing it  with  the  nitrate  of  silver,  or  an  acid.  An  anonymous  writer 
remarks  that  a  similar  operation  has  been  several  times  since  performed 
by  Velpeau,  Boivin,  Laugier,  and  others.  Some  produce  adhesions 
between  the  opposite  surfaces  by  means  of  wounds  made  with  the  knife  ; 
others  by  means  of  sloughs  and  granulating  surfaces,  resulting  from  the 
application  of  escharotics.  Dr.  Ireland  seems  to  attribute  the  merit  of 
devising  this  operation  to  Dr.  Marshall  Hall ;  but  it  is  probable  that 
Girardin,  who  proposed  it  in  the  year  1823,  has  the  claim  of  priority. 
(See  Dublin  Journ.  of  Med.  Science,  vol.  x,  p.  126.)  For  an  historical 
account  of  this  operation,  I  must  refer  to  the  Annali  Universali  di 
Medicina,  edited  at  Milan  by  Omodei,  for  December,  1835.  In  1831 
the  operation  was  performed  by  Dr.  Fricke,  of  Hamburg,  with  a  com- 
pletely successful  result,  and  he  is  a  strong  advocate  for  it. 


572  PROLAPSUS    OF    THE    UTERUS. 

"  The  following  quotation  from  Dr.  Heming's  translation  of  Madame 
Boivin's  work,  p.  53,  affords  some  particulars  of  Dr.  Marshall  Hall's 
operation,  which  appears  to  have  consisted  in  the  excision  of  a  strip  of 
the  mucous  membrane  of  the  vagina  :  'Dr.  Marshall  Hall  has  lately 
cured  a  case  of  complete  prolapsus  uteri  by  artificial  contraction  of  the 
vagina :  a  strip  of  the  mucous  membrane,  an  inch  and  a  half  wide,  was 
removed  along  the  whole  of  the  canal,  and  the  wound  was  sewed  up. 
Wc  hear  nothing  of  hemorrhage,  and  are  assured  that  the  patient 
suffered  neither  pain  nor  fever  after  the  operation.'  In  a  note,  the 
translator  mentions  that  there  was  scarcely  any  hemorrhage,  and  that 
in  November,  1833,  two  years  after  the  operation,  the  uterus  and 
bladder  were  found  by  Mr.  Vincent  to  be  perfectly  supported  in  their 
situation. 

"  Professor  Dieffenbach  has  long  abandoned  the  employment  of 
pessaries  (see  Cruveilhier,  Anat.  Pathol.,  t,  i.,  liv.  16),  and  adopted  the 
plan  of  curing  bad  cases  of  prolapsus  uteri  by  removing  an  oval  piece 
of  the  membrane  of  the  vagina  ;  a  j)lan  suggested  to  him  by  the  obser- 
vation of  a  case  in  which  some  parts  of  the  vagina  sloughed  away, 
while  the  uterus  was  in  a  state  of  prolapsus.  The  uterus  and  the  re- 
mains of  the  vagina  were  reduced  during  the  granulating  process,  and 
the  result  was  a  complete  cure  of  the  disease.  As  this  operation  seems 
to  me  less 'safe  and  eligible  than  the  foregoing  one,  I  omit  the  details 
of  it,  which  may  be  read  in  the  12th  volume  of  the  Dublin  Jour,  of 
Med.  Science,  p.  488,  or  in  Medicinische  Zeitung,  No.  3,  1836.  Cru- 
veilhier would  prefer  the  excision  of  a  few  pieces  of  the  mucous  mem- 
brane, near  the  cervix  uteri,  to  the  method  adopted  by  Dr.  M.  Hall, 
or  Dieffenbach.  Both  these  operations  are  analogous  to  Dupuytren's 
operation  for  the  cure  of  inveterate  cases  of  prolapsus  ani,  being  founded 
on  the  benefit  derivable  from  the  contraction  of  the  cicatrix.  About 
two  months  ago,  I  practiced  Dupuytren's  operation  in  University 
College  Hospital,  whereby  a  prolapsus  of  the  rectum,  of  more  than 
four  years'  standing,  and  which  had  resisted  all  the  ordinary  means, 
was  entirely  cured." 

In  recent  years  modifications  and  extensions  of  the  proceedings  initi- 
ated by  Hamilton,  Marshall  Hall,  Fricke,  and  Dieffenbach,  have  been 
devised  under  a  more  accurate  knowledge  of  the  causes  of  the  displace- 
ment and  of  the  conditions  of  cure.  These  have  accordingly  been 
attended  with  a  far  greater  amount  of  success. 

The  operation  which  first  attracted  attention  arose  out  of  that  for 
restoration  of  the  lacerated  perineum.  It  was  observed  that  prolapsus 
not  infrequently  arose  in  connection  with  rent  perineum.  The  restora- 
tion of  the  perineum,  especially  if  the  rent  extended  through  the 
sphincter  ani,  was  indicated  independently  of  consideration  for  the  pro- 
lapsus. The  restoration  of  the  perineum  was  an  effective  means  of 
restoring  the  integrity  of  the  vagina,  which  is  one  of  the  chief  supports 
of  the  uterus.  Then  as  it  was  observed  that,  in  many  cases,  prolapsus 
uteri  was  complicated  with  vaginal  rectocele,  it  was  hoped  that  by  nar- 
rowing the  vagina  in  its  posterior  wall,  it  would  be  so  far  restored  to 
its  normal  condition,  that  it  would  be  able  to  support  the  uterus.  As 
we  have  seen,  the  posterior  wall  of  the  vagina  and  the  perineum  form 


SURGICAL    OPEEATIONS.  573 

a  most  efficient  support  for  the  anterior  wall.  Much  benefit  might, 
therefore,  reasonably  be  expected  from  making  good  this  part.  Mr. 
Baker  Brown  was  one  of  the  earliest  and  most  energetic  advocates  of 
this  plan.  A  considerable  number  of  operations  of  this  class  have  been 
performed  by  him  and  others,  and  with  varying  degrees  of  success. 
But  there  are  clinical  observations  in  abundance  to  prove  that  it  is 
based  upon  imperfect  appreciation  of  the  causes  of  prolapsus.  In  many 
of  the  cases,  notwithstanding  the  narrowing  of  the  posterior  wall  of  the 
vagina,  and  the  union  of  the  labia  much  anterior  to  the  normal  four- 
chette,  the  prolapsus  after  a  time  returned.  The  true  factors  of  the 
prolapsus  remaining  untouched,  gradually  the  uterus  made  its  way 
down  again,  and  distending  the  new  perineal  floor  appeared  outside 
the  vulva.  It  cannot,  therefore,  be  called  a  radical  cure,  except  in 
those  cases  in  which  vaginal  rectocele  is  the  essential  cause  of  the  pro- 
lapsus. Nor  is  the  relief  often  permanent,  unless  the  vulva  be  almost 
completely  occluded.  It  has  been  seen  that  the  small  vulva  and  per- 
fect hymen  of  the  virgin  are  not  an  absolute  safeguard  against  prolap- 
sus. The  narrowing  of  the  vulva  simply  forms  a  shelf  to  receive  the 
falling  uterus. 

The  operation  is  so  similar  to  that  for  restoration  of  the  rent  peri- 
neum, that  the  description  of  the  two  will  be  given  together. 

An  operation  that  seems  based  upon  a  sounder  view  of  the  pathology 
of  prolapsus,  is  that  proposed  and  practiced  by  Dr.  Marion  Sims  and 
Dr.  Emmet,  of  New  York.  Its  object  is  to  strengthen  or  brace  up  the 
vagina  near  the  junction  of  the  cervix  uteri  with  the  bladder.  It  con- 
sists in  removing  a  portion  of  mucous  membrane  from  the  anterior 
wall  in  the  form  of  a  V,  the  open  part  of  the  V  embracing  the  cervix 
uteri,  and  then  uniting  the  sides  by  sutures.  I  have  performed  this 
operation  as  well  as  the  preceding  one  several  titues.  Although  in 
each  case  the  cure  seemed  perfect  for  some  time  afterwards,  the  parts 
gradually  opened  out  again,  and  the  prolapsus  was  reproduced. 

Then  there  is  a  third  operation  performed  in  yet  a  different  part.  It 
may  be  distinguished  as  Huguier's.  It  is  the  amputation  of  the  hyper- 
trophied  cervix.  The  principle  appears  to  be  different  from  Siras's 
operation,  but  I  think  they  touch  each  other  in  their  mode  of  action. 
It  is  difficult  to  amputate  the  vaginal-portion  of  the  cervix  without 
removing  a  portion  of  the  contiguous  mucous  membrane  in  front ;  and 
w^hen  healing,  a  process  of  cicatricial  contraction  anteriorly  necessarily 
follows.  I  have  seen  this  in  cases  wdiere  nothing  but  amputation  of 
redundant  vaginal-portion  was  contemplated.  But  still  the  proceeding 
has  independent  advantages.  In  the  first  place,  the  elongated  cervix 
is  jpi'o  tanto  shortened ;  and  in  the  second  place,  a  process  of  altered 
nutrition,  attended  by  retraction  in  the  remaining  portion,  is  set  up,  by 
which  a  still  further  shortening  is  effected. 

Huguier's  operation  consists  in  taking  away,  together  with  the  upper 
extremity  of  the  vagina,  the  whole  length  of  the  neck,  and,  if  necessary, 
the  lower  part  of  the  body  of  the  uterus,  removing  it  by  an  incision 
slanting  from  without  inwards,  after  having  previously  detached  the 
bladder  from  the  part  to  be  excised.  In  connection  with  this  rather 
formidable  proceeding,  it  is  desirable  to  state  the  conditions  which,  in 


574  PROLAPSUS    OF    THE     UTERUS. 

Huguier's  judgment,  absolutely  contraindicate  it.  These  are,  a  capa- 
cious pelvis  and  a  large  opening  at  the  vulva,  more  or  less  laceration 
of  the  perineum,  and  considerable  relaxation  of  the  soft  parts  at  the 
pelvic  floor.  If  these  conditions  exclude  the  operation,  the  cases  must 
be  very  rare  in  which  its  performance  would  be  admissible;  and  an 
operation  which  cannot  be  applied  in  the  cases  which  most  urgently 
demand  relief,  can  hardly  be  regarded  as  a  very  important  acquisition 
to  science. 

To  this  criticism  must  be  added  the  serious  dangers  incurred  of 
opening  the  peritoneal  cavity,  or  the  bladder,  of  hemorrhage  from  di- 
viding the  vessels  high  up  at  their  entry  into  the  substance  of  the 
uterus,  and  of  consequent  pysemia.  I  entertain  a  decided  conviction 
that  the  hope  of  relieving  a  condition  not  in  itself  entailing  serious 
danger  to  life,  and  which  is,  moreover,  susceptible  of  being  materially 
mitigated  in  other  ways,  does  not  justify  resort  to  surgical  proceedings 
fraught  with  such  danger. 

In  1860,  Scanzoni^  had  amputated  the  vaginal-portion  sixteen  times  : 
nine  times  with  Siebold's  scissors,  three  times  with  the  galvano-caustic. 
He  says  the  operation  is  always  dangerous. 

Carl  Mayer's  operation  is  described  as  follows:^ 

Because  the  bladder  is  drawn  down  by  the  vaginal -portion,  it  is 
necessary  to  pull  down  the  uterns  strongly,  with  hooks ;  these  being 
held  by  assistants,  the  hypertrophied  portion  is  cut  off  smoothly  with 
a  knife.  Very  profuse  bleeding  follows,  which  is  best  stopped  by 
actual  cautery.  On  account  of  this  bleeding  it  is  especially  necessary 
to  fix  the  uterus,  otherwise  it  quickly  retreats  into  the  pelvis  after  being 
cut,  and  the  arrest  of  the  bleeding  would  be  difficult. 

The  operation  advocated  by  Gustav  Simon,  of  Heidelberg,  is  based 
upon  the  idea  of  strengthening  the  posterior  wall  of  the  vagina  so  as 
to  obtain  a  firm  support  to  the  uterus  and  anterior  wall  of  the  vagina. 
I  am  indebted  to  I)r.  James  R.  Chadwick,  of  Boston,  U.  S.  A.,  for  the 
following  condensed  account.  Simon  calls  it "  posterior  colporrhaphy." 
It  consists  in  removing  the  raucous  membrane  from  a  large  portion  of 
the  posterior  vaginal  wall,  and  bringing  the  two  sides  of  the  denuded 
surface  together,  so  as  to  produce  great  constriction  of  the  vagina. 

The  operation  is  generally  performed  while  the  vagina  is  dilated  lat- 
erally by  a  broad  flat  fenestrated  speculum — a  modification  of  Sims's. 
Through  the  fenestra  the  mucous  membrane  and  a  little  of  the  subja- 
cent tissues  may  easily  be  removed  with  the  scissors  or  bistoury  up  to 
within  f  to  1  inch  of  the  vaginal  insertion  into  the  cervix  uteri.  The 
whole  thickness  of  the  vaginal  wall  should  not  be  cut  away,  for  a  less 
firm  cicatrix  would  then  result.  The  upper  end  of  the  pared  surface 
should  not  be  pointed,  but  almost  square,  so  that,  Avhen  the  healing 
process  is  completed,  a  sort  of  pouch  is  formed  above  the  cicatrix,  into 
which  the  cervix  may  sink  and  be  retained,  instead  of  being  free  to 
insert  itself  into  the  restricted  canal  of  the  vagina,  where  it  would 
gradually  force  its  way  down,  dilating  the  parts,  and  finally  reach  its 

^  BeitrJige  zur  Geburtskunde,  1860. 
"^  Monatsschr.  fiir  Geburtskunde,  1858. 


SURGICAL    OPERATIONS.  575 

former  prolapsed  position.  At  the  vaginal  entrance  the  denudation  of 
the  mucous  membrane  is  carried  out  upon  the  posterior  halves  of  the 
two  labia  majora,  so  that,  Avlien  the  latter  are  approximated  and  unite, 
the  perineum  is  greatly  lengthened  and  additional  support  obtained. 
The  opposite  edges  of  the  wound  are  then  brought  together  by  fine 
silk  sutures,  which  are  allowed  to  remain  four  to  six  days  or  longer. 
A  union  takes  place  throughout  the  whole  extent  of  the  surfaces  thus 
applied  to  each  other,  and  a  firm,  dense,  cicatricial  band  is  obtained, 
running  almost  the  whole  length  of  the  posterior  vaginal  wall.  This 
restricts  the  canal  of  the  vagina,  and  at  the  same  time  imparts  more 
rigidity  to  it,  enabling  it  better  to  support  its  own  weight  and  that  of 
the  uterus.  Professor  Simon  claims  the  following  advantages  for  this 
method  of  operating :  That  it  forms  a  pouch  in  which  the  cervix  rests ; 
that  a  firm  barrier  is  by  it  opposed  to  the  exit  of  the  uterus  at  the 
point  toward  which  that  organ  naturally  gravitates;  and  that  the  vag- 
ina is  made  narrower  and  more  rigid.  In  addition,  the  uterus  is  not 
drawn  down  by  the  contraction  of  the  cicatrix,  as  occurs  in  Sims's  oper- 
ation, owing  to  the  lower  extremity  of  the  cicatrix  in  the  latter  being 
almost  fixed  by  its  attachments  to  the  unyielding  pubic  arch.  Profes- 
sor Simon  says  that  he  has  tried  Siras's  procedure  in  a  number  of  in- 
stances with  temporary  relief,  but  that  after  a  time  the  procidentia  in- 
variably recurred.  He  has  now  operated  more  than  thirty  times  by 
his  own  method,  and  says  that,  with  one  exception,  he  has  effected  per- 
fect and  permanent  cures,  although  the  patients  were  chiefly  poor  peas- 
ants who  did  the  heaviest  kind  of  work  in  the  fields.  Several  of  them 
he  has  now  watched  for  a  number  of  years,  and  there  has  been  no  re- 
turn of  the  procidentia. 

Dr.  Tracy,  of  Melbourne,  performs  an  operation  which  unites  the  an- 
terior and  posterior  colporrhaphy  and  the  perinseorraphy.  The  three 
proceedings  are  carried  out  at  the  same  sitting.  Like  Simon,  he  is  able 
to  say  that  his  patients  are  restored  to  the  capacity  of  earning  their 
living  by  hard  work. 

The  conclusion  I  have  arrived  at  is,  that  in  some  especially  appropri- 
ate cases  each  of  these  three  operations  will  succeed  ;  that  there  are  many 
cases  in  which  one  of  them  singly  will  effect  but  little  good ;  and  that 
a  combination  of  two  or  all  three  will  often  be  necessary  for  complete 
success. 

The  course  to  be  adopted  may  be  stated  as  follows  :  1.  When  there 
is  prolapsus  without  marked  elongation  of  the  cervix,  remove  a  por- 
tion of  the  mucous  membrane  of  the  anterior  wall  of  the  vagina  on 
Sims's  plan.  2.  If  there  is  considerable  elongation,  amputate  a  por- 
tion of  the  redundant  neck,  and  at  the  same  time  remove  a  triangular 
piece  of  the  mucous  membrane  just  in  front  of  the  cervix,  the  base  of 
the  triangle  merging  in  the  stump  of  the  cervix,  and  bring  the  sides 
of  the  triangle  together  by  sutures.  3.  If  there  be  considerable  rec- 
tocele,  with  impairment  of  the  perineum,  perform  the  perineal  opera- 
tion, or  posterior  colporrhaphy.  4.  Where  the  three  conditions  coexist, 
all  three  operations  should  be  performed.  It  will  generally  be  best  to 
do  this  in  successive  operations. 

Although  I  am  more  sanguine  as  to  the  benefits  to  be  derived  from 


576  PROLAPSUS    OF    THE    UTERUS. 

surgery  in  these  cases  than  Dr.  West,  I  cannot  help  concurring  with 
him  in  the  opinion  that  we  still  want  evidence  of  such  an  amount  of 
permanent  success  from  them  as  would  entitle  them  to  the  praise  given 
them  in  some  quarters. 

There  is  undeniable  truth  in  this  passage  from  Dr.  West:  "It  is  sur- 
prising how  much  the  size  of  the  procident  womb  is  reduced  after  its 
return  within  the  vagina  by  a  month's  rest  in  bed,  how  completely  a 
long-standing  ulceration  of  its  orifice  heals,  and  how  effectually  the 
organ  is  retained  afterwards  within  the  pelvis  by  a  bandage.  If  in 
the  majority  of  these  cases  an  operation  were  performed,  a  similar  re- 
sult would  doubtless  be  obtained ;  the  month's  compulsory  rest  in  bed 
would  be  followed  by  the  same  diminution  in  the  size  of  the  uterus, 
and  the  elongated  perineum  would  answer  for  a  time  at  least  the  same 
purpose  as  the  perineal  pad  of  an  ordinary  bandage ;  while  by  slow  de- 
grees the  ligaments  in  the  one  case  as  in  the  other,  might  regain  some 
measure  of  power,  and  the  womb  might  cease  to  fall  down  externally." 

Mr.  Walter  Whitehead,  in  a  very  able  clinical  memoir^  based  on  a 
considerable  number  of  operations  performed  by  himself,  looking  back 
upon  those  operations,  is  strengthened  in  his  opinion  that  to  cure  pro- 
lapsus we  must  aim  more  to  relieve  the  pressure  from  above  than  to 
diminish  the  weight  of  the  uterus,  or  to  increase  the  strength  of  its  sup- 
ports. Such  operations,  he  thinks,  should  be  reserved  for  a  last  re- 
source in  the  isolated  cases,  where  all  other  means  of  supporting  the 
uterus  have  been  found  useless.  Yet  his  mode  of  operating  seems  to 
have  been  well  devised  and  executed,  and  the  success  fair.  It  con- 
sisted in  removing  a  triangle  of  mucous  membrane  from  the  posterior 
vaginal  wall,  the  apex  being  towards  the  os  uteri ;  another  triangle 
from  the  anterior  wall  with  the  apex  downwards,  and  in  amputating 
the  cervix.  Dr.  Gibson  {loco  citato)  also  says  his  personal  experience 
is  adverse  to  the  general  adoption  of  these  operations. 

The  amputation  of  the  elongated  vaginal-portion  demands  great 
care.  There  is  very  serious  risk  of  opening  the  peritoneal  cavity  be- 
hind. Douglas's  pouch,  which  in  the  normal  condition  descends  as  low 
as  the  upper  fourth  of  the  vagina,  that  is  considerably  below  the  level  of 
the  vaginal-portion,  is,  in  the  normal  condition  of  hypertrophic  elonga- 
tion, carried  downwards  in  the  same  proportion.  A  glance  at  the 
drawing.  Fig.  116,  p.  550,  taken  from  nature,  shows  this  very  clearly. 
The  bottom  of  Douglas's  pouch  is  outside  the  vulva,  and  it  would  be 
impossible  to  amputate  any  considerable  part  of  the  protruded  cervix 
without  opening  into  it.  The  accident,  indeed,  has  several  times  hap- 
pened. Marion  Sims  relates  a  case;  Dr.  Meadows  has  related  another, 
and  other  cases  are  known. 

The  accident  is  especially  likely  to  occur  if  the  chain  or  wire-6cra- 
seur  be  used.  During  the  tightening  of  the  chain  especially,  the  trac- 
tion is  apt  to  drag  within  the  grasp  tissue  beyond  the  line  selected  for 
amputation.  To  obviate  this,  two  measures  are  useful.  First,  the  part 
to  be  amputated  may  be  dissected  away  from  its  vaginal  investment, 
so  as  to  isolate  completely  from  the  peritoneum  the  part  which  is  to  be 

1  Manchester  Medical  and  Surgical  Keports,  1871. 


VERSIONS    AND     FLEXIONS.  577 

included  in  the  loop  of  the  chain  or  wire.  Secondly,  the  cervix  may 
be  transfixed  by  a  long  straight  needle  just  above  the  part  where  the 
chain  or  wire  is  applied.  This  will  present  an  eifectual  barrier  to  the 
in-dragging  of  any  tissue  beyond  what  is  intended.  The  accident  may 
also  be  avoided  by  dissection  and  amputation  with  the  knife. 

The  opening  of  the  peritoneum  is  not,  however,  necessarily  fatal,  and 
the  surgeon  should  be  prepared  to  meet  the  dangers  attending  it. 


CHAPTER  XLIV. 

DISPLACEMENTS   OF  THE  UTERUS  {contimied). 
OBLIQUE    OE    LATERAL    INCLINATIONS;    ELEVATION;    DEPRES- 
SION; ELONGATION  BY  STRETCHING  AND  PRESSURE;   DISLO- 
CATIONS   OE    UTERUS    BY    EXTERNAL    PRESSURE;    VERSIONS 
AND  FLEXIONS  ;  ANTEVERSION  ;  ANTEFLEXION. 

A  CONTEOVEESY  was  long  keenly  waged,  and  I  do  not  know  that 
it  is  even  yet  set  at  rest,  as  to  which  was  the  antecedent,  and  therefore 
causative  condition — namely,  engorgement  and  inflammation  of  the 
uterus,  or  displacement.  One  school  held  that  the  displacement  en- 
tailed the  engorgement,  the  other  school  .maintained  that  the  engorge- 
ment produced  the  displacement. 

There  was  right  on  both  sides.  But  both  sides  greatly  overlooked  a 
third  chapter  in  the  history — namely,  the  frequent  occurrence  of  flex- 
ions and  versions  as  a  congenital  disposition. 

Some  of  the  anomalies  of  position  are  congenital,  some  acquired.  I 
have  been  brought  by  long  observation  to  the  conclusion  that  the  con- 
genital aberrations  from  the  normal  position  are  far  more  frequent  than 
is  commonly  supposed. 

Among  the  more  important  congenital  forms  is  the  extra-median 
position  of  the  uterus  loith  eccentric  implantation  into  the  vaginal  roof. 
The  uterus  lies  to  right  or  left  out  of  the  median  line,  its  form  being 
symmetrical,  the  broad  ligament  of  one  side  is  small,  the  other  by  so 
much  the  wider.  On  touching  by  vagina  the  finger  passes  by  one  side 
of  the  vaginal-portion  into  an  elevated  empty  roof,  and  on  the  other 
side  into  a  shallow  space.  This  anomaly,  says  Rokitansky — and  from 
clinical  observations  on  the  living  I  venture  to  confirm  his  statement — 
is  not  uncommon. 

The  oblique  position.     This  occurs  sometimes  with  the  well-formed 

37 


578  DISPLACEMENTS    OF    THE    UTERUS. 

uterus,  but  commonly  it  is  combined  with  oblique  or  one-sided  forma- 
tion of  the  uterus ;  and  sometimes  a  congenital  lateral  inflexion  is 
found. 

Inflammatory  adhesions  may  bind  the  uterus  down  in  almost  any 
position.  Thus,  in  Bartholomew's  Museum  Q^o.  32.38)  is  a  specimen 
where  there  has  been  inflammation  of  the  pelvic  portion  of  peritoneum, 
and  irregular  adhesions  have  formed  about  the  ovaries.  Fallopian  tubes, 
and  broad  ligaments.  The  left  broad  ligament  is  much  contracted,  and 
the  body  of  the  uterus  is  thus  drawn  to  the  left  side,  so  that  its  axis  is 
almost  at  a  right  angle  to  that  of  the  vagina. 

Dislocation  of  the  Uterus  upwards  [Elevation  of  the  Uterus). — The 
uterus  rises  when  enlarging  from  pregnancy,  fibroid  tumors,  accumu- 
lation of  blood,  mucus,  or  other  matters  in  its  cavity ;  or  it  may  be 
drawn  or  pushed  upwards  by  tumors,  enlarged  ovaries,  hematocele,  or 
by  adhesions,  or  hernia  of  the  tubes  or  ovaries,  which  will  drag  it  to 
the  side  of  the  hernia.  Elevation  of  the  uterus  is  attended  by  elonga- 
tion or  stretching  of  the  vagina,  smoothing-out  of  its  folds,  unfolding 
of  the  duplicature  which  constitutes  the  roof  of  the  vagina,  and  the 
vaginal-portion ;  elongation  of  the  cervix,  atrophic  attenuation,  and 
lastly,  lesion  of  continuity  of  the  cervix.  Sometimes  this  combined 
process  of  compression  and  stretching  effects  the  actual  separation  of 
the  body  of  the  uterus  from  its  neck.  Mr.  Nann  exhibited  to  the 
Pathological  Society  (see  Pathol.  Trans.,  vol.  x)  a  uterus,  the  body  of 
which  was  above  twice  or  thrice  its  normal  size,  and  which  had  under- 
gone nearly  complete  isolation  from  its  cervix,  which  was  smaller  than 
normal.  The  attenuation  was  due  to  the  pulling  of  an  ovarian  tumor 
which  was  removed  by  gastrotomy. 

Dr.  Hare  exhibited  to  the  same  society  an  enormous  ovarian  tumor 
weighing  106  lbs.,  removed  from  a  dead  woman.  The  vagina  was 
stretched  to  6i  inches  long,  it  was  inclined  very  much  towards  the 
left,  and  at  its  extremity  the  os  uteri  was  represented  by  a  small  aper- 
ture which  led  into  the  cavity  of  the  uterus.  This  organ,  like  the 
vagina,  was  firmly  adherent  to  the  anterior  surface  of  the  tumor,  and, 
like  it,  was  exceedingly  elongated,  being  7^  inches  in  length.  Its 
body  was  also  much  thinned  out  and  flattened.  This  specimen  shows 
that  the  uterus,  if  subjected  to  dragging  and  pressure  from  an  ovarian 
tumor  being  adherent  to  it,  is  liable  to  similar  transformations  as  the 
Fallopian  tube  in  like  case.  I  have  seen  quite  similar  changes  pro- 
duced in  the  uterus  by  its  outer  wall  forming  part  of  the  sac  of  an 
extra-uterine  gestation. 

Analogous  conditions  may  be  produced  by  fibroid  tumors  in  the 
uterus  itself. 

Simple  compression  between  a  tumor  and  the  symphysis  pubis  may 
produce  similar  attenuation  of  the  uterus. 

The  uterus  may  enter  into  the  contents  of  a  hernial  sac,  constituting 
hysterocele.  It  has  been  found  in  inguinal  and  femoral  hernia,  in 
hernial  openings  of  the  abdominal  aponeurosis  between  tlie  recti  mus- 
cles; in  an  ischiatic  hernia,  and  in  hernia  of  the  foramen  ovale. 

Certain  displacements  of  the  uterus  are  caused  by  pressure.  Thus, 
a  tumor  behind  the  uterus,  or  a  hsematocele  in  Douglas's  pouch,  will 


VERSIONS    AND    FLEXIONS.  579 

push  the  organ  hodilj  forwm^d,  without  affecting  its  axis  of  suspension, 
compressing  it  against  the  symphysis  pubis.  I  have  known  a  large 
accumulation  of  faces  in  the  rectum  produce  the  same  displacement, 
and  that  to  the  extent  of  causing  retention  of  urine. 

A  tumor  in  the  side  of  the  pelvis  may  push  the  uterus  over  to  the 
opposite  side.  The  most  frequent  are  ovarian  tumors.  Inflammatory 
deposit  in  one  broad  ligament  may  drag  it  towards  the  same  side. 

In  either  of  these  cases  the  uterus  is  liable  to  become  elongated  as 
well  as  deflected  by  the  pressure.  In  some  cases  of  ovarian  tumor  in 
the  earlier  stages  the  fundus  of  the  uterus  is  pulled  towards  the  affected 
ovary,  throwing  the  os  upwards  in  the  opposite  direction,  so  that  the 
uterine  axis  lies  almost  across  the  pelvis. 

The  Inclinations  or  Versions  and  Flexions  of  the  Uterus. 

It  is  desirable  to  start  by  defining  the  meaning  attached  to  the  terms 
employed  in  describing  the  displacements  of  the  uterus.  Xaturally,  we 
understand  by  displacement,  any  deviation  from  the  normal  position 
of  the  uterus.  If  we  could  exactly  determine  the  normal  position,  we 
should  have  a  fixed  point  of  departure  from  which  to  measure  the  vari- 
ous deviations.  But  this  fixed  point  it  is  not  easy  to  settle.  We  must 
allow  a  certain  range  of  location  to  a  mobile  organ  like  the  uterus. 
Assuming,  however,  as  we  may,  that  the  uterus  is  suspended  in  the 
upper  part  of  the  pelvic  cavity,  so  that  its  fundus  is  on  a  level  with  the 
plane  of  the  pelvic  brim,  that  its  inclination  coincides  nearly  with  the 
axis  of  the  pelvic  inlet,  and  that  it  floats  between  bladder  and  rectum 
about  midway  between  the  symphysis  pubis  and  the  sacrum,  but  some- 
what nearer  to  the  symphysis,  we  shall  have  a  standard  position  suffi- 
ciently defined  for  clinical  purposes. 

Another  point  necessary  to  determine  is  what  Aran  calls  the  axis  of 
suspension  of  the  uterus.  This  is  defined  as  follows :  Just  above  the 
vaginal-portion  the  cervix  adheres  to  the  bladder ;  behind,  it  is  free, 
and  receives  about  the  level  of  the  union  with  the  bladder,  the  utero- 
sacral  or  Douglasian  ligaments.  This  point  is  the  axis  of  suspension. 
Around  this  the  body  of  the  uterus  can  move  in  all  directions.  This 
axis  is,  however,  susceptible  of  displacement  en  masse,  owing  to  the 
flexibility  and  elasticity  of  the  constituent  parts.  It  ascends  in  the 
recumbent  and  prone  postures  and  before  the  examining  finger;  it 
descends  in  the  erect  posture,  and  in  prolapsus,  and  in  straining  efforts. 

We  may  define  version  as  inclination  or  nutation  of  the  uterus  for- 
wards or  iaackwards,  or  to  either  side,  with  regard  to  its  normal  axis, 
the  uterus  retaining  its  normal  slight  curve.  The  uterus,  in  version, 
rotates  upon  its  axis  of  suspension,  so  that  if  the  fundus  dip  forwards 
and  downwards,  the  vaginal-portion  will  rise  in  the  opposite  direction; 
and  if  on  the  other  hand  the  fundus  rise  and  incline  backwards,  the 
vaginal-portion  will  come  forwards.  In  the  first  case  there  will  be  a 
corresponding  degree  of  what  I  have  called  anterior  vaginal  roof- 
stretching  ;  in  the  second  place  there  will  be  a  corresponding  degree  of 
posterior  vaginal  roof-stretching.  The  anterior  vaginal  roof-stretching 
reaches  its  highest  degree  in  early  pregnancy,  when  anteversion  of  the 


580  DISPLACEMENTS    OP    THE    UTERUS. 

enlarging  uterus  throws  up  and  back  the  vaginal-portion  under  the 
sacral  promontory,  carrying  the  vaginal  roof  back  with  it.  The  dia- 
gram, Fig.  49,  p.  139,  will  make  this  clearer.  Of  course  it  is  not  to 
be  taken  that  the  definition  given  is  strictly  true.  Especially,  the  axis 
of  suspension  is  rarely  fixed.  It  moves  en  masse  with  the  bladder, 
which  helps  to  form  it.  It  is  deflected  a  little  backwards  or  forwards 
when  the  uterus  inclines  or  is  flexed.  This  varies  with  the  size  of  the 
uterus  and  other  circumstances. 

Flexion  consists  in  bending  of  the  uterus  upon  itself.  The  axis  of 
suspension  may  not  greatly  shift.  In  anteflexion  the  body  is  bent  for- 
wards, the  vaginal-portion  points  downwards,  being,  perhaps,  but  not 
necessarily,  thrown  up  a  little  backwards.  In  retroflexion,  the  body  is 
bent  backwards,  the  vaginal-portion  still  points  downwards,  and  is, 
perhaps,  but  not  necessarily,  thrown  a  little  forwards  and  upwards. 
In  short,  the  flexions  often  involve  a  little  version,  that  is,  a  slight 
rotation  of  the  whole  uterus  upon  its  axis  of  suspension. 

The  annexed  diagram  will  serve  to  illustrate  the  versions  and  flexions 
of  the  uterus.     (See  Fig.  119,  p.  581.) 

In  version,  the  entire  uterus  revolves  on  its  transverse  axis,  main- 
taining its  ordinary  shape.  As  a  lever,  the  dipping  of  the  body  or 
upper  end. elevates  the  lower  end  in  the  opposite  direction  in  a  corre- 
sponding degree.  In  flexion,  the  lever  may  be  considered  as  broken 
in  its  middle,  so  that  dipping  of  the  body  gives  only  a  small  degree  of 
elevation  to  the  other  end.  Thus  the  os  in  version  looks  either  for- 
wards or  backwards,  and  is  high  in  the  pelvis;  whilst  in  flexion,  the 
OS  still  looks  downwards,  and  is  more  central  and  lower  in  the  pelvis. 

As  anteversion  and  anteflexion  are  exaggerations  of  the  normal  con- 
ditions, we  may  fitly  notice  these  first.  Anteversion  was  carefully 
described  by  Levret.  During  the  period  of  development,  the  uterus  is 
bent  upon  itself,  forming  a  curve  or  flexure,  with  the  concavity  directed 
forwards.  This  state  of  anteversion  and  anteflexion,  commonly  con- 
tinues in  a  more  or  less  marked  degree  until  the  advent  of  puberty. 
It  frequently  persists  in  virgins  and  the  sterile  throughout  life.  Ante- 
flexion, indeed,  is  a  condition  disposing  to  sterility,  and  is  often  asso- 
ciated with  a  conical  vaginal-portion,  a  small  os  uteri  externum,  and  a 
short  vagina,  all  indications  of  imperfect  development.  Dysmenorrhoea, 
with  or  without  excess  of  menstrual  flow,  commonly  attends.  When 
not  of  primitive  origin,  it  is  sometimes  induced  by  the  development  of 
a  fibroid  tumor  in  the  anterior  wall  of  the  uterus.  The  bend  is  com- 
monly at  the  junction  of  the  body  and  neck  ;  and  here  some  degree  of 
atrophy  is  often  found.  The  fundus  falls  into  the  peritoneal  fold  be- 
hind the  bladder,  and  thus  sinks  into  the  bladder,  depressing  it,  lead- 
ing to  irritability  of  the  organ  and  dysuria. 

During  early  pregnancy,  the  fundus  of  the  uterus  inclines  more 
upwards  and  forwards,  the  6s  tilting  more  upwards  under  the  prom- 
ontory, thus  increasing  its  natural  anteversion.  But,  the  fundus  point- 
ing above  the  symphysis  pubis,  as  the  uterus  enlarges  it  grows  out  of 
the  pelvis,  clearing  the  brim,  and  generally  rising,  so  as  to  assume  a 
direction  more  approaching  coincidence  with  that  of  the  axis  of  the 
brim.     The  bladder  also  filling  below,  tends  to  lift  the  fundus  out  of 


VERSIONS     AND     FLEXIONS. 


581 


the  pelvis.  In  some  rare  cases,  however,  of  early  pregnancy,  the  fundus 
has  been  locked  behind  the  symphysis  pubis  in  complete  anteversion, 
forming  the  counterpart  to  the  retroversion  of  the  gravid  uterus. 
(See  V.  Hiiter,   Monatsschr.  fiir  Geburtskunde,   1863.)      The  more 


Diagram  to  illustrate  versions  and  flexions  of  the  uterus. 

A  B.  Axis  of  inlet  of  pelvis,    c  d.  Plane  of  brim,    e  f.  Kormal  axis  and  position  of  uterus. 

e /.  Retroversion.    .9  ^.  Anteversion.     e'/'- Retroflexion,    p' A'.  Anteflexion. 


common  form  of  anteversion  of  pregnancy,  however,  is  rarely  marked 
before  the  fifth  or  sixth  month,  and  then  there  is  usually  flexion  as 
well.  It  occurs  especially  in  M^omen  who  have  had  many  children, 
and  whose  abdominal  walls  are  exceedingly  relaxed,  the  reed  muscles, 
perhaps,  having  been  stretched  apart.  Hohl  says  it  is  favored  by  too 
great  inclination  of  the  pelvis.  (Hohl,  Lehrb.  der  Geburtshiilfe,  1862.) 
It  is  favored  by  wearing  stays,  the  back  of  which  presses  on  the  grow- 
ing uterus  at  the  fundus,  helping  to  throw  this  part  downwards  and 
forwards.  In  this  way,  at  term,  we  find  the  uterus  lying  on  the  sym- 
physis, the  cervix  curving  a  little  downwards  into  the  pelvis  behind, 
whilst  the  body  and  fundus  hang  downwards  in  front  of  the  pelvis, 
sometimes  even  approaching  the  knees.  The  management  of  this  con- 
dition is  of  course  entirely  obstetrical.  It  is  carefully  described  in  my 
work  on  "  Obstetric  Operations." 

Anteversion  also  occurs  from  the  body  of  the  uterus  being  over- 
weighted, as  by  hypertrophy,  when  there  is  ever  so  little  forward  incli- 
nation of  the  organ.     The  uterus  moves  as  a.  lever  upon  its  axis  of 


582  ANTEFLEXION     OF    THE    UTEBUS. 

suspension.  Its  longer  arm  is  above  this  axis  or  hypomochliou,  so 
that  the  most  moderate  increase  of  bulk  and  weight  at  the  extremity 
of  this  arm  weighs  it  down. 

This  condition  of  hypertrophic  enlargement  of  the  body  of  the  uterus 
is  not  uncommon.  I  have  seen  it  arise  from  imperfect  involution,  from 
congestion  kept  up  by  menorrhagia,  overexertion,  and  tumors.  In  women 
past  the  climacteric  the  foundation  is  commonly  laid  during  the  child- 
bearing  period,  but  upon  this  foundation  of  subinvolution,  a  super- 
structure of  farther  hypertrophic  growth  is  laid  by  the  obstruction  to 
the  portal  circulation  which  so  frequently  exists  after  the  climacteric. 
When  this  process  is  once  set  going,  it  tends  to  maintain  itself.  There 
is  a  more  or  less  active  developmental  force  kept  up  in  the  uterus  ; 
blood  is  attracted  to  it,  retained  in  it ;  there  is  hsemostasis,  and  this 
condition  constantly  leads  to  increased  deposit  and  bulk  of  the  organ 
affected.  This  attraction  of  blood  is  continually  liable  to  excess ;  and 
then  the  uterus  being  an  organ  designed  for,  and  habitually  disposed 
to,  the  shedding  of  blood,  hemorrhage  takes  place.  Long  past  the 
climacteric,  and  therefore  probably  long  past  the  influence  of  ovarian 
stimulus,  these  hemorrhages  observe  a  degree  of  order  in  recurrence. 
They  do  not,  indeed,  recur  with  such  striking  regularity  as  do  the 
menstrual  discharges ;  but  still  they  evince  the  subjection  of  the 
economy  to  the  law  of  periodicity. 

The  inflexions  are  frequent,  both  congenital  and  acquired.  These  are 
of  all  degrees,  varying  from  the  slightest  bending,  or  bowing,  to  the 
extreme  degree  in  which  the  body  is  doubled  up  upon  the  cervix  as  in 
Figs.  123,  124,  pp.  590,  591. 

A  slight  degree  of  anteflexion  must  be  considered  as  normal.  It  is 
the  persistence  of  the  infantile  state.  Indeed,  the  axis  of  the  uterus  is 
rarely  quite  straight.  This  axis  is  represented  by  a  slight  curve,  passing 
through  the  cavities  of  the  cervix  and  body.  It  corresponds  more  or 
less  closely  with  the  curvilinear  axis  of  the  pelvis.  This  is  a  point 
important  to  remember,  because  the  instrument-makers  invariably  sell 
the  uterine  sound  set  at  an  angle  from  the  shoulder,  which  marks  the 
length  of  the  two  uterine  cavities,  this  intra-uterine  portion  being  quite 
straight.     To  pass  in  easily,  this  portion  should  be  gently  curved. 

When  the  anteflexion  exceeds  a  slight  degree,  it  must  be  regarded 
as  abnormal ;  indeed,  symptoms  more  or  less  distressing  rarely  fail  to 
attend. 

Many  anteflexions  are  congenital.  Many  also  are  acquired.  These 
latter  are  produced,  1,  by  a  fibroid  tumor  being  developed  in  the 
anterior  wall  of  the  fundus ;  2,  by  dropping  forward  of  the  body  of 
the  uterus  when  in  a  state  of  increased  weight,  bulk,  and  flaccidity 
after  labor. 

This  may  happen  immediately  after  labor,  especially  when  there  is 
general  as  well  as  local  loss  of  tone  from  flooding.  Or  it  may  occur 
more  gradually  in  a  secondary  manner,  from  the  uterine  body  remain- 
ing bulky  and  flabby,  from  want,  first,  of  due  muscular  contraction,  and 
secondly,  from  defective  involution.  Both  conditions  may  occur  after 
premature  labor  and  abortion.  Both  may  be  due  to,  or  at  least  asso- 
ciated with,  retention  of  a  portion  of  ovum.    Whether  portions  of  ovum 


ANTEFLEXION    OP    THE     UTERUS.  583 

be  retained  or  not,  both  lead  to  obstinate  secondary  hemorrhage,  and 
dispose  to  hyperplasia  or  infarction  of  the  uterus,  and  consequent 
troubles. 

1.  The  uterus  is  occasionally  bound  down  in  anteversion  by  adhesions. 
These  may  be  the  result  of  pelvic  peritonitis  from  hsematocele  in  the 
anterior  peritoneal  pouch,  from  puerperal  inflammation,  or  other  causes. 
The  following  history  is  not  very  uncommon  :  A  woman  who  had  never 
been  pregnant  had  menstruated  regularly  until  six  months  previously, 
when  she  had  "  inflammation,"  and  great  pain  in  the  abdomen,  for 
which  she  was  leeched  and  blistered.  She  was  menstruating  at  the 
time  of  the  attack.  Menstruation  irregular  since;  has  dragging  pains 
in  the  lower  abdomen  ;  great  irritability  of  the  bladder,  frequent  desire 
to  pass  water.  The  body  of  the  uterus  is  enlarged ;  it  is  fixed  in  ante- 
version,  as  if  growing  to  the  fundus  of  the  bladder ;  it  cannot  be  moved ; 
the  cervix  moves  in  a  limited  extent ;  there  is  a  creamy  discharge  from 
the  OS.  In  this  case,  it  seemed  clear  that  there  had  been  peritonitis, 
leaving  adhesions  which  bowed  down  the  fundus  uteri. 

2.  Another,  and  not  infrequent  cause  of  antev^ersion  is  coitus.  Under 
certain  conditions  of  form,  the  vaginal-portion  is  driven  backwards  and 
upwards,  and  inclination  of  the  fundus  naturally  ensues. 

3.  A  tumor  in  the  fundus  or  anterior  wall  of  the  uterus. 

In  the  extreme  anteflexions,  the  vaginal-portion  points  downwards 
or  a  little  backwards,  an  angle  is  felt  in  front  of  the  cervix,  and  the 
body  lies  horizontally  forwards,  or  its  posterior  surface  is  turned  for- 
wards, so  that  the  fundus  rolls  over  into  the  vesico-vaginal  pouch  of 
the  peritoneum. 

4.  Virchow  bases  the  origin  of  anteflexion  on  the  relations  between 
uterus,  bladder,  and  rectum,  and  chiefly  on  the  pressure  which  the 
distended  bladder  exerts  on  the  cervix  in  the  region  of  the  os  internum, 
where  the  peritoneal  boundary  of  the  distended  bladder  ceases.  The 
atrophy  of  tissue,  found  principally  at  this  place,  is  caused  by  this 
pressure. 

In  some  few  cases  there  is  flexion  below  the  os  internum,  about  the 
middle  of  the  cervix ;  and  occasionally  there  is  a  double  flexion,  one 
backwards  in  the  middle  of  the  cervix,  one  forwards  at  the  os  internum, 
so  that  the  uterus  and  its  cervix  describe  a  bending  like  an  S. 

5.  One  cause  of  anteflexion  undoubtedly  lies  in  partial  atrophy  in 
the  region  of  the  uterine  neck.  This  part  becoming  comparatively 
weaker,  the  body  is  bent  down  upon  the  cervical  portion,  under  the 
superincumbent  pressure  of  the  intestines. 

6.  Martin,  of  Berlin,  describes  as  a  cause  of  anteflexion  or  retro- 
flexion the  subinvolution  of  the  placental  site.  Thus,  if  the  placenta 
had  grown  to  the  posterior  wall,  and  this  portion  remain  imperfectly 
reduced,  being  thicker  and  longer  than  the  anterior  wall,  the  fundus 
will  be  pushed  over  forwards,  producing  anteflexion.  If  the  placenta 
had  grown  to  the  anterior  wall,  the  contrary  condition  of  retroflexion 
would  be  produced.     Martin  gives  figures  drawn  from  cases  observed. 

Rokitansky  says  excessiv^e  inclination  of  the  pelvis  disposes  to  ante- 
version. 


584  ANTEFLEXION    OF    THE    UTEEUS. 

Like  most  other  diseases  of  the  uterus,  but  in  a  more  marked  degree, 
displacements  act  in  three  ways,  producing  three  sets  of  symptoms. 

1.  Functional,  relating  to  the  organ  itself. 

2.  Mechanical,  by  pressure  upon  surrounding  organs. 

3.  Rem,ote,  or  constitutional,  due  to  the  reaction  of  the  two  former. 

1.  The  Functional  Symptoms  of  Anteversion. — Slight  excess  of  inclina- 
tion msLj  entail  little  distress.  But  if  the  axis  of  the  uterus  become 
horizontal,  so  that  the  fundus  rests  upon  the  symphysis  pubis,  or  gets 
behind  it,  troublesome  symptoms  arise.  In  most  cases,  probably  some 
enlargement  of  the  body  of  the  uterus  precedes  the  inclination.  But  in 
all  cases  increased  enlargement  of  this  part  is  sure  to  follow.  This  is 
the  almost  necessary  consequence  of  the  impediment  which  the  dis- 
placement offers  to  the  return  of  blood  from  the  uterine  vessels.  This 
leads  to  chronic  hypersemia,  and  hence  a  frequent  symj)tom  is  menor- 
rhagia  or  metrorrhagia.  Leucorrhoea,  another  evidence  of  hypersemia, 
being  another  mode  by  which  the  gorged  tissues  seek  relief,  follows 
the  hemorrhage.  The  excess  of  blood  collected  in  the  uterus,  and  the 
obstacle  presented  to  its  escape  by  the  abnormal  position  and  by  the 
swelling  of  the  tissues  cause  dysmenorrhoea.  Dyspareunia  is  a  very 
common  symptom. 

2.  The  Pressure  Symptoms. — The  enlarged  fundus  presses  upon  the 
bladder,  and  irritates  this  organ.  Hence  frequent  urgency  to  pass 
water,  without  the  want  being  ever  satisfied.  The  patient  may  have 
to  get  out  of  bed  many  times  a  night.  There  is  dysuria  as  well,  and 
occasionally  retention,  for  which  the  catheter  may  be  necessary.  That 
bladder  distress  is  not  more  frequent  is  explained  by  the  fact  that  the 
uterus  often  assumes  an  oblique  position,  the  fundus  not  lying  in  the 
median  line,  but  to  one  side,  thus  avoiding  the  bladder.  The  strain- 
ing causes  pelvic  pain.  The  axis  of  the  uterus  being  preserved,  the 
vaginal-portion  rises  under  the  promontory,  protruding  the  posterior 
wall  of  the  vagina,  buries  itself  in  the  rectum,  causing  a  distinct  promi- 
nence in  that  cavity.  Hence  there  is  often  dyschezia,  leading  to  irrita- 
bility of  the  bowel,  tenesmus,  diarrhoea,  or  constipation.  The  pain  is 
commonly  increased  in  the  upright  posture  and  by  exertion.  Hence 
the  patient  is  soon  induced  to  lead  an  inactive  life. 

I  have  known  this  projection  into  the  bowel  provoke  most  intense 
suffering.  It  has  led  to  the  suspicion  of  disease  of  the  bowel,  especi- 
ally of  stricture. 

The  strong  projection  against  one  point  of  the  vagina  also  causes  irri- 
tation, leucorrhoea,  and  sometimes  even  ulceration  at  this  part. 

3.  The  remote  or  sympathetic  and  constitutional  symptoms  are  those 
which  ensue  upon  most  other  uterine  diseases.  There  is  irritation  of 
the  nervous  centres,  and  consequent  disordered  distribution  of  nerve 
force  to  the  economy,  entailing  various  functional  disturbances.  And 
after  a  time  the  hemorrhagic  and  leucorrhoeal  dischargies  impoverish 
the  blood,  and  lead  to  impaired  nutrition. 

The  general  course  of  anteversion  is  towards  aggravation.  There  is 
little  tendency  to  spontaneous  reposition.  Some  amount  of  accommo- 
dation in  the  course  of  time  may  lead  to  tolerance.  But  as  a  rule  the 
artificial  reduction  of  the  uterus  to  its  normal  position  is  indicated. 


ANTEVERSION    OF    THE    UTERUS.  585 

In  addition  to  the  symptoms  which  are  traced  to  the  abnormal  posi- 
tion of  the  uterus,  there  are  always  others,  which  are  due  to  the  com- 
plicating conditions,  as  the  pain,  metrorrhagia,  leucorrhoea,  arising 
from  congestion  and  hypertrophy.  The  suiFerings  are  commonly  much 
increased  at  the  onset  of  the  menstrual  periods,  which  are  marked  by 
severe  uterine  colic,  attended  often  by  vomiting,  hysteria,  and  other 
nervous  disorders. 

Diagnosis  of  Anteversion. 

The  diagnosis  is  not  usually  difficult.  We  have,  in  the  first  place, 
a  series  of  subjective  symptoms  already  described.  The  absolute  diag- 
nosis is  made  out  by  physical  exploration.  1.  Vaginal  touch  discovers 
the  OS  uteri  high  up  under  the  promontory  of  the  sacrum,  and  gener- 
ally pointing  backwards ;  feeling  along  the  roof  and  anterior  wall  of 
the  vagina  in  front  of  the  os  uteri,  we  find  this  in  a  state  of  more  or 
less  tension,  strained  backwards  by  the  retreating  cervix.  Through 
this  stretched  roof  we  feel  the  solid  mass  of  the  uterus.  2.  Now,  com- 
bining abdominal  touch  with  the  vaginal  touch,  we  can  grasp  the  body 
of  the  uterus  between  the  hand  outside  and  the  finger  inside ;  the  fun- 
dus is  felt  through  the  abdominal  wall,  above  or  behind,  but  mostly 
above  the  symphysis;  pushing  the  fundus  backwards,  we  feel  the  whole 
uterus  move  upon  the  examining  finger.  3.  By  rectal  touch  combined 
with  abdominal  touch,  this  is  made  even  clearer,  as  the  finger  in  the 
rectum  gets  more  completely  behind  and  above  the  os  uteri,  so  that  the 
finger  on  the  os  and  the  hand  on  the  fundus  measure  the  whole  length 
of  the  uterus  between.  4.  The  uterine  sound,  moderately  curved,  is 
passed  into  the  os  uteri,  whilst  the  vaginal-portion  is  depressed  by  the 
finger  above  it,  the  handle  of  the  instrument  then  carried  backwards, 
directs  the  point  forwards  into  the  body  of  the  uterus.  It  will  often 
pass  ^,  or  I  inch,  or  more,  beyond  the  normal  length,  and  when  it  has 
gone  the  full  length,  the  vaginal-portion  being  brought  downwards 
by  the  instrument,  the  fundus  rises  and  is  felt  more  distinctly  above 
the  symphysis  by  the  hand  outside.  Pressing  upon  the  fundus,  move- 
ment is  imparted  to  the  whole  uterus  and  sound,  which  is  very  per- 
ceptible to  the  hand  holding  the  instrument. 

The  foregoing  methods  of  examination  will  also  give  accurate  esti- 
mate of  the  increase  of  bulk  from  hyperplasia,  and  by  irregularity  of 
form  of  the  presence  of  a  tumor.  The  range  of  mobility  of  the  point 
of  the  sound  will  also  give  an  idea  of  the  enlargement  of  the  cavity  of 
the  uterus,  and  if  there  is  anything  inside  it. 

But  since  early  pregnancy  may  be  the  cause  of  the  enlargement  and 
anteversion,  it  is  of  primary  importance  to  exclude  the  probability  of 
this  condition  before  using;  the  sound.  If  menstruation  have  been  sus- 
pended  for  a  month  or  more ;  if  the  os  uteri  feel  soft ;  if  there  be  the 
elastic  anterior  roof  stretching  (see  p.  139)  characteristic  of  pregnancy ; 
if  there  be  the  dark-red  coloration  of  the  vjagina  and  vulva;  if  there  be 
present  the  recognized  mammary  changes,  lay  aside  the  sound. 

I  have  several  times  known  the  enlarged  anteverted  or  anteflected 
uterus  projecting  over  the  symphysis  mistaken  for  a  tumor.     Unless 


586  ANTEVERSION    OF    THE     UTERUS. 

the  sound  be  used  it  may  be  difficult  to  convince  a  person  who  has 
fallen  into  this  error  of  the  true  nature  of  the  case.  But  in  practiced 
hands  the  sound  is  rarely  necessary  to  make  out  a  satisfactory  diagnosis. 
In  most  cases  it  will  be  useful,  as  the  first  step  in  physical  diagnosis, 
to  empty  the  bladder. 

Treatment  of  Anteversion. 

The  indications  are  threefold  :  1.  To  allay  the  complications,  as  con- 
gestion, or  inflammation  of  the  uterus,  which  either  preceded  or  arose 
after  the  displacement.  I  place  this  indication  first,  because  the  com- 
plications are  often  the  most  immediate  causes  of  distress,  and  because, 
until  they  are  somewhat  relieved,  mechanical  means  to  rectify  the 
malposition  cannot  be  borne.  If,  then,  there  be  marked  increase  of 
bulk,  with  tenderness  of  the  uterus,  it  may  be  desirable  to  apply  four 
or  five  leeches  to  the  roof  of  the  vagina,  or  double  that  number  to  the 
abdomen  above  the  pubes.  The  patient  should  keep  the  recumbent 
posture,  the  dorsal  being  the  best  adapted  to  counteract  anteversion. 
Salines  and  sedatives  will  be  necessary.  And  some  advantage  may  be 
derived  from  tepid  vaginal  irrigation,  and  the  use  of  sedative  pessaries 
containing  morphia  or  belladonna. 

If  the  OS  uteri  externum  be  narrow,  we  may  commonly  greatly 
promote  the  subsidence  of  congestion  by  the  bilateral  incision  of  the 
vaginal-portion.  This  is  not  only  a  very  eifectual  method  of  local 
depletion,  but  the  freer  opening  of  the  canal,  by  giving  readier  exit  to 
menstrual  blood  and  mucous  secretions,  obviates  a  great  source  of 
future  engorgements,  and  hence  of  spasmodic  attacks. 

When  the  first  indication  has  been  accomplished,  we  may  proceed  to 
carry  out  the  second  and  third.  The  second  is  to  rectify  the  malposi- 
tion. The  mechanical  contrivances  designed  for  this  purpose  are  nu- 
merous, but  inferior  in  precision  and  efficiency  to  those  which  we  pos- 
sess for  the  relief  of  the  backward  displacements.  The  first  condition 
to  fulfil  is,  as  far  as  possible,  to  take  off  the  superincumbent  weight 
of  the  intestines.  In  many  cases  there  is  a  disposition  to  pendulous 
abdomen,  and  hence  to  swagging  of  the  intestines  forwards.  This,  be- 
sides pressing  directly  upon  the  posterior  wall  of  the  uterus,  which 
looks  upwards,  involves  a  sluggish  imperfect  action  of  the  intestinal 
canal,  with  lodgment  of  faeces  and  distension  with  air.  Duly  supported, 
this  fault  is  greatly  corrected.  This  is  effected  by  the  adaptation  of  a 
good  abdominal  belt,  which  supports  and  strengthens  the  abdominal 
wall  from  its  lowest  part.  In  some  cases  where  the  enlarged  fundus 
uteri  projects  sensibly  above  the  symphysis,  the  lower  margin  of  the  belt 
may  be  made  to  seize  this  part  and  directly  lift  it  up,  thus  taking  off  the 
pressure  from  the  bladder.  To  do  this  the  more  effectually,  a  pad  may 
be  inserted  in  the  belt.  The  amount  of  success  to  be  derived  from  the 
belt  will  depend  greatly  upon  the  intelligence  and  skill  of  the  maker. 

2.  The  second  condition  is  to  support  the  anteverted  fundus  from 
within.  The  great  difficulty  in  contriving  a  pessary  which  will  do  this, 
lies  in  the  circumstance  that  pessaries  naturally  seek  by  their  upj)er  end 


TREATMENT. 


587 


to  rest  in  the  posterior  vaginal  cul-de-sac,  that  is,  to  get  behind  the 
cervix  uteri  whilst  the  lower  end  will  rest  upon  the  anterior  vaginal 
wall. 

Regarding  the  uterus  as  a  lever  which  has  to  be  made  to  rotate  upon 
its  axis  of  suspension,  we  have  to  consider  upon  which  arm  of  the  lever 
we  shall  act.  We  may,  for  example,  push  up  the  longer  arm  by 
applying  some  elevating  power  to  the  fundus  ;  or  we  may  draw  down 
the  shorter  arm  by  pulling  upon  the  vaginal-portion.  Instruments 
have  been  devised  upon  both  these  principles.  Amongst  those  intended 
to  lift  up  the  fundus  may  be  mentioned  the  modifications  of  the  air- 
pessary  described  by  Gillebert  d'Hericourt ;  and  a  modification  of  Dr. 
Roper's  described  in  the  Catalogue  of  Instruments  of  the  Obstetrical 
Society,  which  bears  in  front  of  the  axis  of  suspension. 

Dr.  Simpson,  the  present  Professor  of  Obstetrics  at  Edinburgh,  has 
devised  a  pessary  for  anteversion,  of  which  he  speaks  highly. 

Amongst  the  most  ingenious  contrivances  is  that  of  Dr.  Graily 
Hewitt.  Attaching  great  and,  as  I  venture  to  believe,  undue  impor- 
tance to  the  evils  associated  with  anteversion,  he  has  expended  much 
labor  in  the  construction  of  a  pessary  for  lifting  up  the  fundus  of  the 
uterus. 

Professor  Thomas  has  also  devised  an  anteversion  pessary.  Its 
basis  is  a  Hodge's  lever ;  but  attached  to  the  anterior  aspect  of  this 
basis  is  a  horseshoe  lever,  moving  upon  elastic  joints.  The  curved 
part  of  this  horseshoe  rises  up  behind  the  symphysis  pubis,  and  lifts 
up  the  fundus  uteri.  The  size  of  the  instrument  requires  careful  adap- 
tation to  the  case  in  hand.  I  have  derived  considerable  satisfaction 
from  this  instrument.     The  figures  120,  121,  will  serve  to  show  its 


Fig.  120. 


Fig.  121. 


Thomas's  anteversion  pessary. 

The  elastic  horseshoe  doubled  upon  the 

Hodge  basis  for  introduction. 


Thomas's  anteversion  pessary. 

The  elastic  horseshoe  relaxed  as  when  in 

use. 


application  and  mode  of  action.  It  ought  not  to  be  so  large  as  to  dis- 
tend the  vagina  much,  or  to  take  a  point  d^appui  against  any  part  of 
the  pelvic  wall. 

Dr.  Playfair  has  effected  a  modification  of  Thomas's  pessary  which 
.seems  to  be  an  improvement.  It  consists  in  making  the  uterine  arm  of 
elastic  watch-spring  covered  with  rubber. 

The  intra-uterine  stem-pessary  has  been  so  adapted  as  to  bring  down 
the  cervix.     Thus  a  stem  two,  or  two  and  a  half  inches  long,  inserted 


588 


ANTEVERSION    OF    THE    UTERUS. 


into  the  uterus,  is  connected  by  its  lower  end  with  a  wire,  which  is 
brought  outside  the  vagina  and  is  fixed  by  a  disk  to  the  anterior  sur- 
face of  the  pubes.  This  form  of  instrument  cannot,  I  think,  be  com- 
mended. It  is  not  safe.  Its  action  is  not  in  accordance  with  the  prime 
law  of  all  good  pessaries.  It  does  not  sufficiently  respect  the  natural 
mobility  of  the  uterus.  Hence  the  organ  is  exposed  to  shock,  friction, 
and  inflammation. 

Dr.  Clay's  modification  of  his  wire-pessary  is  better.  He  makes  a 
loop,  which  grasps  the  cervix  uteri,  pulls  it  down,  and  is  secured  by 
an  external  pad. 

I  have  made  the  acquaintance  of  many  of  the  instruments  for  cor- 
recting malpositions  through  their  failure  in  particular  cases.  I  have 
been  called  upon  to  remove  them  when  they  were  the  causes  of  distress 
and  even  of  danger.  I  feel,  however,  that  it  would  be  wrong  to  draw 
from  this  kind  of  experience  an  unqualified  adverse  opinion.  The  use 
of  these  same  instruments  may  in  many  other  cases  have  been  bene- 
ficial ;  and,  naturally,  these  cases  would  not  be  so  likely  to  come  under 
the  observation  of  another  physician. 


Fig.  122. 


Thomas's  anteversion  pessary  in  action. 
The  dotted  line  shows  the  fundus  uteri  elevated  by  the  pessary.— (R.  B.) 

A  pessary  which  compels  the  wearer  to  forego  exercise,  to  keep  on 
the  sofa,  may  be  pronounced  a  failure.  Under  these  conditions  the 
health  must  give  way ;  there  can  be  no  improvement  in  tissue. 


ANTEFLEXION.  589 

Surgery,  again,  offers  resources  for  the  relief  of  this  malposition. 
It  is  obvious  that  if  we  could  so  shorten  the  anterior  wall  of  the  va- 
gina at  its  upper  part  as  to  drag  upon  the  cervix,  we  should  bring  this 
part  of  the  uterus  downwards  and  forwards.  This  may  in  some  cases 
be  accomplished  by  removing  a  triangular  piece  of  mucous  membrane 
from  the  vagina  in  front  of  the  cervix,  and  contracting  the  part  by 
bringing  the  edges  together.  The  object  might  also  be  attained  by 
establishing  a  cicatrix  at  this  part  by  potassa  cum  calce  or  the  actual 
cautery. 

3.  Concurrently  M'ith  the  endeavor  to  correct  the  malposition,  it  is 
desirable  to  carry  out  the  third  indication,  namely,  to  improve  the 
general  tone  and  nutrition.  To  complete  and  especially  to  maintain  a 
cure,  we  want  good  muscular  fibre  and  sound  tissues.  The  first  con- 
dition to  obtain  these  is  obviously  healthy  nutrition,  the  capacity  for 
converting  food  into  healthy  structure.  Malpositions  are  greatly  de- 
pendent upon  weak  tissues  and  bad  nutrition.  We  may  aid  in  correct- 
ing this  fault  by  two  methods.  First,  by  placing  the  patient  in  good 
hygienic  conditions,  and  the  use  of  tonic  medicines,  as  strychnine,  iron, 
quinine;,  and,  secondly,  by  local  applications  to  the  weak  tissues  of  the 
vagina  and  uterus.  Some  amount  of  uterine  catarrh  is  almost  con- 
stant. This  is  best  treated  by  introducing  two  or  three  grains  of  solid 
sulphate  of  zinc  into  the  uterine  cavity  every  four  or  five  days,  or  by 
the  occasional  application  of  solid  nitrate  of  silver  to  the  same  part. 
Astringents  to  the  vagina,  in  the  form  of  injections  or  pessaries,  will 
lend  material  help. 

Anteflexion. 

The  causes  of  anteflexion  are  similar  to  those  which  lead  to  antever- 
sion,  excepting  coitus.  To  these  may  be  added  a  state  of  weakness  at 
the  juncture  of  cervix  and  body  from  relaxation,  which  disposes  the 
organ  to  bend  at  this  point.  It  may  be  congenital  or  acquired.  The 
congenital  anteflexion,  being  a  persistence  of  the  natural  condition  in 
an  exaggerated  form,  tends  to  be  corrected  with  time,  and  especially  by 
pregnancy,  should  this  take  place.  But  not  rarely  the  bending  is  much 
in  excess  of  the  normal  degree.  The  organ  has  quite  the  form  of  a 
retort,  the  fundus  nodding  so  low  that  the  summit  looks  down,  and  is 
almost  on  a  level  with  the  os.  There  is  commonly  some  degree  of 
general  deficiency  of  sexual  development  associated  with  this  condition, 
more  especially  a  small  conical  vaginal-portion  with  a  minute  os  exter- 
num, and  a  short  vagina.  This  form  may  lead  to  no  trouble  until  the 
advent  of  puberty  or  marriage.  It  is  difficult  to  form  even  a  rough 
estimate  of  its  influence  as  a  cause  of  dysmenorrhoea  or  of  other  disorder, 
since  it  is  only  those  cases  in  which  actual  disorder  arises  that  come 
under  medical  care.  There  may  then  possibly  exist  many  cases  of  ex- 
treme anteflexion,  unattended  by  distress.  On  the  other  hand,  it  is 
certain  that  in  many  women  who  seek  relief  for  menstrual  disorder, 
dyspareunia,  sterility,  we  find  marked  anteflexion ;  and  I  am  disposed 
to  infer  that  anteflexion  rarely  fails  to  entail  trouble.  It  is  obvious 
that  extreme  flexion  of  the  uterus,  with  a  depending  fundus,  must  pre- 
sent a  mechanical  difficulty  to  the  flow  of  the  menstrual  fluid.     Hence 


590 


ANTEFLEXION    OF    THE    UTERUS. 


a  degree  of  retention,  causing  pain,  and  engorgement  of  the  organ  ;  and 
sooner  or  later  hypertrophy  of  the  fundus.  Especially  in  married  life 
these  conditions  are  apt  to  be  followed  by  metritis.  Catarrh  and  dila- 
tation of  the  cavity  of  the  body  of  the  uterus  are  rarely  absent.  Retro- 
grade ovarian  irritation  is  induced.  If  under  the  general  engorgement 
of  the  ovaries,  tubes,  and  uterus  attending  a  menstrual  period,  any 
perturbing  cause,  as  cold,  shock,  sexual  intercourse  intervene,  the 
transition  into  inflammation  in  the  form  of  metritis,  oophoritis,  peri- 
tonitis, or  perimetritis  is  easy. 

When  relaxation  of  the  uterine  tissues  and  the  surrounding  structures 
has  taken  place,  as  from  general  loss  of  tone,  or  from  local  disorder,  the 
fundus  may  be  forced  down  upon,  or  behind,  the  bladder  by  the  super- 
incumbent pressure.  This'may  take  place  gradually,  or  suddenly  under 
violent  exertion  or  succussion. 


Extreme  anteflexioD  of  Uie  iit  rus.     (Nat.  sizj,  London  Hospital  Museum.) 
a.  The  OS  uteri;   6.  tha  fundus,  both  looking  forward. 


The  same  features  are  also  well  shown  in  Fig.  124,  taken  from 
Boivin  and  Dnges. 

If  not  existing  before  the  anteflexion,  congestion,  hyperplasia,  hyper- 
trophy, are  pretty  sure  to  be  developed  afterwards,  and  to  aggravate 
the  displacement. 

Anteflexion  has  little  tendency  to  spontaneous  cure.  Rokitansky 
says  that  flexions  sometimes  tend  to  pass  into  versions,  that  is,  the 
bent-down  cervix  rises  so  that  the  uterus  straightens  itself.  It  is  intel- 
ligible that  the  uterus  which  has  suffered  sudden  anteflexion  may  grad- 
ually, under  a  resilient  force,  lessen  the  bend  imparted  to  it.  But  to 
do  this,  the  rising  cervix  must  drag  upon  the  cervico-vesical  connec- 
tions, and  either  pull  up  the  base  of  the  bladder,  or  the  connective 
tissue  between  must  stretch.  There  must,  in  short,  be  shifting  of  the 
axis  of  suspension  of  the  uterus.  No  doubt  one  or  other  or  both  these 
events  take  place  in  primary  anteversion,  and  it  is  therefore  not  im- 
probable that  they  may  take  place  in  the  secondary  anteversion  of 
Rokitansky.  But  clinical  evidence  of  this  change  has  escaped  me.  I 
have  known  many  cases  of  anteflexion  that  have  lasted  as  such  for 
lengthened  periods. 

Anteflexion,  like  anteversion,  produces  three  sets  of  symptoms.  The 
first  are  due  to  changes  in  the  uterus  itself.  These  cannot  be  called 
special  to  anteflexion.  They  consist  in  difficult  function,  as  dysmenor- 
rhoea,  in  the  symptoms  proper  to  congestion,  inflammation,  and  hyper- 


DIAGNOSIS    OF    ANTEFLEXION. 


591 


trophy.  Hence,  menorrhagia  and  lencorrhoea  are  very  coramon,  Bnt 
in  many  cases  of  congenital  anteflexion,  menorrhagia  does  not  occnr, 
or  at  least  is  not  a  continuous  symptom. 


Anteflexion  of  tlie  uterus.    (Krom  Boivin  and  Dug^s.) 

a.  The  fundus  uteri;  b,  the  vaginal-portion— both  looking  forward,    c.  The  vagina. 

e  e.  Fallopian  tubes,    d  d.  The  ovaries. 

The  second  set  of  symptoms  are  those  produced  by  the  relations  of 
the  displaced  uterus  to  surrounding  organs.  Irritation  of  the  bladder, 
leading  to  desire  to  often  void  it,  is  frequent. 

The  third  set  of  symptoms  are  the  remote  or  constitutional. 

Diagnosis  of  Anteflexion. — All  trustworthy  means  of  diagnosis  are 
centred  in  physical  exploration.  1st.  Vaginal  digital  touch  feels  the 
OS  uteri  centrally  or  perhaps  anteriorly  or  posteriorly  situated,  point- 
ing downwards  or  a  little  backwards.  Passing  the  tip  of  the  finger 
round  the  vaginal-portion,  it  feels  behind,  the  elastic  roof  of  the  vagina 
at  the  angle  of  reflection  from  the  vaginal-portion,  and  no  solid  substance 
through  it ;  in  front  between  the  vaginal-portion  and  the  symphysis 
pubis  it  feels  the  vaginal  roof,  and  through  this  resting  upon  it  a 
rounded  solid  body ;  on  tracing  this  solid  body  backwards  towards  the 
vaginal-portion,  a  deep  sulcus  is  felt  between  them  at  the  point  of 
union.  2d.  The  vaginal  touch  is  assisted  and  corrected  by  abdominal 
palpation  with  the  other  hand.  In  this  way  we  may  embrace  the 
body  of  the  uterus  between  the  two  hands,  and  movements  imparted 
to  it  by  either  hand  will  be  propagated  to  the  other.  (See  Fig.  125, 
page  592.)  3d.  We  may  further  verify  the  information  gathered  by 
the  pre(!eding  methods,  and  extend  it,  by  the  sound.  This  should  be 
curv(id  according  to  the  idea  we  have  formed  as  to  the  extent  of  the 
flexion,  and  introduced  with  the  concavity  forwards.     When  the  point 


592 


ANTEFLEXION    OF    THE     UTEEUS. 


has  reached  the  os  uteri  internum,  the  handle  is  carried  backwards  so 
as  to  direct  the  point,  into  the  cavity  of  the  body.  The  passage  of  the 
isthmus  may  often  be  facilitated  by  tilting  up  the  body  of  the  uterus 
with  the  finger  so  as  to  straighten  the  organ.  When  the  point  has 
reached  the  fundus  we  have  warning  by  the  objective  sense  of  resist- 
ance, and  by  the  subjective  sense  of  pain.  Then  by  depressing  the 
handle  of  the  sound,  the  fundus  is  further  lifted  up,  so  that  the  hand 

Fig.  125. 


Showing  diagnosis  of  anteiiexion  of  uterus  by  combined  abdomino-vagiual  touch. 


above  the  symphysis  feels  it  supported  on  the  sound.  This  is  brought 
into  clearer  evidence  by  giving  gentle  lateral  and  elevating  movements 
to  the  sound,  wlien  the  uterus  carried  on  it  will  be  felt  to  move  in  ac- 
cordance under  the  hand.  The  sound  thus  passing  along  the  entire 
length  of  the  mass  felt  in  front  of  the  vaginal-i)ortion,  demonstrates 
that  it  is  the  uterus  and  not  a  body  external  to  it.  It  gives  further 
information  as  to  the  size,  shape,  and  relations  of  the  uterus.  It 
takes  measures  of  the  length  of  the  uterus,  it  enables  us  by  palpation 


TREATMENT.  593 

to  distinguish  its  outline,  and  by  moving  the  uterus  we  get  some  idea 
of  its  relations. 

The  conditions  which  are  most  likely  to  simulate  anteflexion  of  the 
uterus  are :  pregnancy ;  a  fibroid  tumor  in  the  anterior  wall  of  the 
uterus;  a  tumor  in  the  bladder;  or  a  consolidated  hsematocele  in  the 
ante-uterine  peritoneal  pouch,  or  in  the  connective  tissue  between 
bladder  and  uterus.  These  two  last  conditions  might  easily  pass  for 
anteflexion,  if  we  trusted  to  the  touch  alone.  Both  give  the  sensation 
of  a  solid  body  separated  by  a  groove  or  depression  from  the  vaginal- 
portion  ;  and  both  may  be  felt  behind  and  above  the  symphysis  pubis. 
The  sound  will  usually  make  matters  clear.  If  the  mass  be  a  fibroid, 
the  sound  will  not  pass  into  it  in  the  direction  of  its  axis;  it  will  prob- 
ably run  up  in  a  straighter  direction,  more  in  the  axis  of  the  pelvic 
brim  behind  the  tumor,  when  we  shall  realize  the  existence  of  a  thicker 
mass  between  the  sound  and  the  finger  in  the  vagina,  or  the  finger 
above  the  pubes;  we  shall  make  out  the  increased  bulk  and  weight  of 
the  body ;  we  shall,  perhaps,  ascertain  that  the  shape  is  not  uniform 
like  that  of  the  uterus,  but  bulging  more  on  one  side;  the  mass  will 
be  harder  than  the  uterine  wall ;  and  in  some  cases  the  sound  will 
only  pass  in  a  tortuous  course. 

The  tumor  in  the  bladder  may  be  distinguished  by  fixing  the  uterus 
on  the  sound,  when  the  tumor  can  be  made  to  move  or  glide  inde- 
pendently. 

The  ante-uterine  hsematocele  may  be  distinguished  by  a  similar 
course  of  analysis  ;  the  mass  is  felt  to  be  distinct  from  the  uterus  which 
is  moved  apart  upon  the  sound.  The  history,  also,  may  help.  But 
pelvic  diseases  present  no  exception  to  the  general  fallacy  of  history,  so 
that  I  am  accustomed  to  rely  upon  no  diagnosis  which  cannot  be  rea- 
sonably based  upon  clinical  objective  signs. 

The  Treatment  of  Anteflexion. 

The  rectification  of  the  anteflected  uterus  is  more  difficult  than  that 
of  the  anteverted  one.  We  can  get  no  power  upon  the  cervical  arm  of 
the  lever  which  will  have  much  effect  in  lifting  up  the  fundus.  We 
have  to  rely  mainly  upon  propping  up  the  fundus  from  below;  upon 
taking  off  the  superincumbent  weight;  upon  straightening  the  cervix 
by  inserting  a  more  or  less  rigid  internal  rod;  and  upon  diminishing 
the  unnatural  weight  of  the  body  of  the  uterus.  This  last  object  it 
should  be  our  endeavor  to  attain  first,  inasmuch  as  it  may  depend  upon 
congestion  and  inflammation,  and  this  state  forbids  the  application  of 
mechanical  means.  A  few  leeches  to  the  roof  of  the  vagina  in  front  of 
the  OS  uteri  may  be  useful  if  there  is  obvious  fulness,  with  pain  and 
increased  heat  of  the  part;  emollient  injections  will  help.  During 
this  preliminary  treatment  rest  in  the  recumbent  posture  must  be  en- 
joined. 

If  the  patient  be  very  stout,  with  flaccid  abdominal  walls,  a  good 
belt  will  aid  in  diminishing  the  pressure  upon  the  bowed-down  uterus. 
Keeping  the  bowels  open  by  suitable  aperients,  and  the  large  intestine 
clear  by  an  occasional  enema,  must  on  no  account  be  omitted. 

38 


594  ANTEFLEXION     OF    THE     UTEEUS. 

The  uterus  may  be  propped  up  from  below  by  one  of  Thomas's 
pessaries.  But  the  effect  of  pressure  so  applied  to  the  fundal  arm  of 
the  uterine  lever  will  sometimes  be  to  cause  the  uterus  to  revolve  upon 
its  axis  of  suspension,  the  cervix  retaining  its  flexion,  and  the  os  coming 
forwards. 

To  straighten  the  cervix  there  are  two  adjuvants.  First,  we  may 
pass  an  intra-uterine  pessary.  If  this  can  be  borne,  it  may  be  suffi- 
cient of  itself,  or  if  not,  it  will  convert  the  uterus  into  so  good  a 
lever  that  the  external  pessary  will  act  efficiently.  The  best  internal 
pessary  for  this  purpose  is  Wright's,  made  of  vulcanite.  Its  expanding 
branches,  diverging  when  in  situ,  tend  to  lift  up  the  fundus. 

The  axis  of  the  cervix  may  also  be  brought  into  coincidence  with 
that  of  the  body  of  the  uterus  by  inserting  a  laminaria  tent.  The 
dilatation  of  the  entire  uterine  canal  thus  effected  will  not,  indeed,  be 
permanent,  but  it  may  be  a  step  by  which  other  means  may  be  utilized. 
It  is  also  serviceable  by  giving  free  vent  for  any  fluids  that  may  have 
accumulated  in  the  cavity  of  the  uterus.  I  do  not,  however,  advise 
the  use  of  tents  as  a  general  rule.  They  are  not  free  from  objection  on 
the  score  of  inflammatory  complications  and  pyasmia. 

In  a  considerable  proportion  of  cases,  some  straightening  may  be 
obtained  by  the  bilateral  division  of  the  vaginal-portion.  Or,  as  Sims 
has  shown,  we  may  obtain  a  straighter  canal  by  dividing  the  vaginal- 
portion  through  the  posterior  lip.  This  it  effects  by  splitting  the  lowest 
incurved  portion  of  the  canal. 

Occasional  passage  of  the  uterine  sound  will  be  useful  not  only  to 
verify  the  condition  from  time  to  time,  but  also  to  straighten  the  uterus 
and  lift  the  fundus  out  of  its  unnatural  depression. 

If  the  displacement  be  associated  with  weak  fibre,  it  is  only  by  slow 
degrees  that  the  uterus  acquires  the  power  of  preserving  its  proper 
form  and  position.  Some  months,  perhaps  many,  will  be  required  for 
a  cure ;  and  we  must  ever  be  prepared  for  disappointment.  Tolerance 
or  accommodation  may,  however,  come  with  time,  and  when  the  peri- 
odical congestion  of  ovulation  has  ceased,  the  troubles  of  anteflexion 
may  subside. 

The  cure  will  be  even  more  protracted  if  there  is  any  marked  degree 
of  atrophy  or  thinning  at  the  angle  of  the  flexion.  In  this  case  new 
growth  must  take  place.  In  proj^ortion  as  this  process  goes  on,  the 
inferior  or  anterior  wall  gets  strengthened,  as  we  may  imagine  it  would 
if  we  could  apply  a  splint  to  its  length.  I  believe  that  in  some  cases 
in  which  the  patient  has  not  reached  the  climacteric,  this  does  take 
place  when  the  uterus  is  maintained  in  a  straightened  condition  by 
mechanical  supports.  And  I  also  believe  that  atrophy  at  this  point  is 
not  a  necessary  condition  of  flexion. 


EETROVEESION — RETROFLEXION.  595 


CHAPTER  XLV. 

EETKOVERSION  ;    RETROFLEXION. 

Ketroveesion  simple  is,  I  believe,  not  common  in  the  unmarried. 
Nor  is  it  very  common  in  the  married  who  have  not  had  children.  It 
occurs  most  frequently  as  a  condition  of  prolapsus,  under  which  head 
it  is  described.  It  is  not  nearly  so  frequent  as  retroflexion.  This  may, 
perhaps,  be  partly  accounted  for  by  the  tendency  Avhich  the  uterus  has 
to  bend  at  the  junction  of  neck  and  body  when  force  is  applied  to  the 
fundus.  Thus,  when  the  fundus  is  once  inclined  a  little  backwards,  as 
in  the  early  stage  of  retroversion,  receiving  the  superincumbent  weight 
more  and  more  upon  its  anterior  surface,  it  rolls  back,  whilst  the  cer- 
vix, being  held  down  on  its  axis  of  suspension,  maintains  its  position. 

The  history  of  retroversion  and  retroflexion  of  the  gravid  womb  I 
have  drawn  with  some  fulness  in  my  work  on  "  Obstetric  Operations," 
and  do  not  therefore  enter  upon  the  subject  here. 

The  course  and  effects  of  retroversion  do  not  require  lengthened  de- 
scription, since  a  great  part  of  the  history  of  retroversion  belongs  prop- 
erly to  that  of  prolapsus.  The  healthy  uterus  is  not  very  liable  to  re- 
troversion. The  displacement  is  usually  secondary  upon  engorgement, 
enlargement  of  the  body  of  the  uterus,  upon  atrophy  or  upon  the  pres- 
ence of  a  tumor.  I  have  also  known  it  to  be  produced  by  the  residual 
adhesions  of  a  retro-uterine  hsematocele.  If  the  uterine  body  be  a 
little  enlarged  from  any  cause,  as  during  menstruation,  sudden  exer- 
tion or  succussion  may  throw  it  back,  more  or  less  descent  attending. 
This  may  be  distinguished  as  acute  retroversion.  As  in  acute  prolapsus, 
there  will  be,  first,  the  pain  produced  by  the  violence  done  to  the  uterine 
supports.  This  will  last  for  several  days,  or  even  weeks.  Pelvic  peri- 
tonitis may  even  be  provoked.  In  the  next  place,  and  often  very 
quickly,  irritation  of  the  bladder  and  rectum  ensues,  and  there  may 
even  be  retention  of  urine,  and  of  fseces,  and  tenesmus.  Then  the  ob- 
struction caused  by  the  altered  relations  of  the  parts  to  the  circulation 
of  the  uterus,  leads  to  increased  engorgement  of  the  organ,  especially 
of  its  body.  The  uterus  itself  becomes  the  seat  of  pain  of  a  throbbing 
character,  with  a  sense  of  heat,  local  oppression,  and  bearing-down. 
This  tenderness  is  also  productive  of  dyspareunia.  The  pain  radiates 
to  the  sacral  and  lumbar  regions,  to  the  groins  and  down  the  thighs, 
generally  down  one  leg  more  than  the  other.  There  is  often  a  con- 
siderable amount  of  constitutional  disturbance  evinced  by  accelerated 
pulse,  and  by  nervous  phenomena,  as  hysteria. 

When  retroversion  is  produced  gradually,  it  is  most  commonly  pre- 
ceded by  some  morbid  alteration  in  the  substance  of  the  uterus ;  and 
the  symptoms  proper  to  the  complicating  disease  will  be  added  to  those 
due  to  the  displacement,  but  the  local  symptoms  will  be  less  acute. 


596  BETEOVEESrON    OF    THE    UTEEUS. 

That  retroversion  is  a  condition  of  prolapsus  is  especially  true  of 
what  may  be  called  the  se7iile  retroversion.  In  this  case  it  is  not  nec- 
essary that  there  should  be  any  antecedent  disease  of  the  uterus.  The 
essential  preliminary  condition  is  atrophy.  The  uterus  has  shrunken 
below  its  normal  dimensions;  the  absorption  of  the  fat  which  makes 
up  the  padding  of  the  pelvis,  and  the  loss  of  tonicity  of  the  tissues  gen- 
erally, facilitate  prolapsus.  As  the  uterus  falls,  its  fundus  rolls  back, 
so  that  when  prolapsus  has  passed  into  procidentia,  the  bag  formed  by 
the  inverted  vagina  contains  the  uterus  completely  retroverted,  where 
it  may  be  grasped  and  surrounded  by  the  fingers. 

This  position  of  the  uterus  may  also  be  found  in  young  women  as 
the  result  of  prolapsus  after  labor,  the  posterior  wall  of  the  vagina  being 
weakened  perhaps  by  perineal  laceration. 

Retroversion  may,  as  Rokitansky  says,  and  as  Dr.  Protheroe  Smith 
has  much  insisted  upon,  be  promoted  by  a  very  small  inclination  of 
the  pelvis.  That  is,  if  we  suppose  the  axis  of  the  pelvis  to  approach 
the  brute  type,  the  axis  of  the  brim  being  parallel  with  the  vertebral 
column,  the  pressure  of  the  superincumbent  intestines  will  take  the 
fundus  uteri  in  front,  and  thus  throw  it  over  backw-ards.  In  the  stoop- 
ing or  kneeling  posture  the  inclination  of  the  pelvis  is  much  lessened. 
Hence  the  distress  often  felt  in  this  posture. 

The  Diagnosis  of  Retroversion. — Physical  exploration  reveals  the 
exact  condition.  Vaginal  touch  shows  the  os  uteri  tilted  forwards  be- 
hind the  symphysis  pubis;  the  vaginal  roof  behind  the  vaginal-portion 
is  put  on  the  stretch,  forming  an  inclined  plane,  tending  downwards 
and  backwards,  thus  reversing  the  normal  direction  of  the  vaginal  canal. 
Through  this  stretched  vaginal  roof,  the  cervix  and  body  of  the  uterus 
are  felt  extending  in  a  line  with  the  vaginal-portion,  as  a  solid  rounded 
mass,  which  makes  the  posterior  wall  of  the  vagina  protrude  forwards, 
compressing  it  against  the  anterior  wall  and  the  bladder.  Often,  how- 
ever, the  uterus  takes  an  oblique  direction  ;  its  long  axis  being  not 
quite  coincident  with  the  conjugate  diameter  of  the  pelvis.  This  is 
why  the  ])ladder  and  rectum  so  often  escape  disturbing  pressure.  Pres- 
sure upon  the  uterus  in  recent  cases  will  generally  evoke  acute  pain, 
and  in  chronic  cases  some  degree  of  tenderness  on  touch  is  rarely  absent. 
There  is  commonly  a  free  secretion  of  mucus,  the  exponent  of  the  local 
congestion. 

The  position  is  made  still  clearer  by  rectal  touch.  The  finger  in  the 
rectum  easily  makes  out  the  enlarged  rounded  fundus  of  the  uterus 
projecting  into  the  rectal  cavity.  It  lies  in  Douglas's  pouch.  The  tip 
of  the  finger  can  in  most  cases  without  difficulty  travel  all  round  the 
circumference  of  the  uterine  mass,  getting  above  it,  whilst  at  the  same 
time,  by  abdominal  touch,  we  endeavor  to  make  the  two  examining 
hands  meet,  we  place  the  whole  mass  whose  nature  we  are  seeking  to 
identify  between  them ;  and  thus,  having  brought  it,  isolated  from  the 
abdominal  cavity  into  a  limited  space,  we  can  define  its  outline  and 
relations,  and  determine  accurately  its  nature. 

The  last  and  most  conclusive  evidence  is  obtained  by  the  sound. 
The  patient  lying  on  her  left  side,  the  examiner  feels  for  the  os  uteri, 
and  guides  the  point  of  the  sound,  which  is  very  gently  curved,  into 


TREATMENT.  597 

it  with  the  concavity  turned  backwards ;  when  it  has  run  about  an 
inch,  it  will  generally  be  found  to  pass  more  easily  by  lifting  up  the 
fundus  of  the  uterus  with  the  guiding  finger,  whilst  the  point  of  the 
sound  is  directed  backwards ;  by  this  consentaneous  manoeuvre  the 
sound  will  penetrate  to  the  fundus,  of  which  intimation  is  obtained  by 
the  arrest  of  the  instrument,  by  the  sense  of  pain  which  almost  invaria- 
bly attends  touching  the  fundus,  and  by  the  length  to  which  the  sound 
has  penetrated — that  is,  two  and  a  half  inches  or  more. 

The  final  evidence  is  obtained  by  what  may  be  called  the  crucial  test 
of  replacing  the  uterus.  The  handle  of  the  sound  is  made  to  describe 
a  large  radius,  by  the  gentlest  possible  movement,  so  as  to  make  the 
point  in  the  uterus  turn  with  the  smallest  possible  radius,  until  its  con- 
cavity looks  forwards  ;  then  the  handle  is  gently  carried  backwards  in 
a  straight  line,  or  if  the  uterus  is  sensibly  enlarged,  a  little  obliquely 
backwards,  so  as  to  lift  it  on  one  side  of  the  projecting  promontory  of 
the  sacrum.  The  uterus,  thus  forming  a  common  lever  with  the  sound 
inside  it,  has  its  fundus  brought  forwards  towards  the  pubes,  where  it 
may  now  be  felt  through  the  abdominal  walls,  the  region  hitherto 
occupied  by  the  solid  rounded  mass  being  left  void. 

Demonstration  cannot  be  more  complete.  The  patient  is  usually 
conscious  of  immediate  relief. 

The  conditions  that  may  lead  astray  are — 1.  A  tumor  in  the  posterior 
wall  of  the  uterus.  This  may  be  distinguished  by  the  sound  passing 
well  in  front  of  the  mass  behind  the  vaginal-portion  along  the  natural 
direction  of  the  uterine  cavity,  or  even  more  anteriorly,  and  especially 
by  our  being  enabled  to  feel  the  fundus  uteri  supported  on  the  sound 
above  the  pubes.  2.  A  retro-uterine  hseraatocele.  This  is  distinguished 
from  retroversion  by  the  same  means ;  we  make  out  the  uterus  well  in 
front  of  the  tumor ;  and  usually  the  os  points  downwards  or  backwards, 
and  the  whole  uterus  is  pushed  forwards  upon  the  symphysis.  3.  A 
mass  of  hardened  scybala  in  the  rectum.  Such  a  mass,  coming  down 
to  a  level  or  nearly,  with  the  cervix  uteri,  is  at  times  very  deceptive. 
It  may  be  distinguished  by  its  yielding  under  the  pressure  of  the  finger  ; 
and  subsequently  by  the  sound  showing  the  fundus  uteri  to  be  in  a 
different  place. 

But,  in  fact,  there  can  be  no  ambiguity  or  doubt,  if  we  carry  out 
the  diagnostic  manoeuvres  above  described.  The  shifting  of  the  firm 
rounded  mass  felt  behind  the  vaginal-portion  to  a  position  in  front  by 
the  sound,  so  that  it  is  felt  above  the  symphysis,  is  characteristic,  and 
conclusive  of  retroversion. 

We  must,  however,  bear  in  mind  that  the  fundus  of  the  uterus  may 
be  tied  down  by  adhesions,  so  that  it  becomes  unsafe  to  attempt  to  lift 
it  up  by  the  sound.  The  occasional  occurrence  of  this  complication  dic- 
tates great  care  and  gentleness  in  reversing  the  point  of  the  sound. 
The  handle  should  be  carried  back  with  the  minimum  of  force,  the 
lightest  touch  only  should  be  added  to  help  its  gravity,  and  if  any  re- 
sistance be  experienced,  the  attempt  at  reduction  must  be  abandoned. 

The  treatment  of  retroversion  consists  mainly  in  keeping  the  uterus 
in  its  normal  position  by  mechanical  support  until  its  natural  supports 
have  recovered  the  power  of  doing  their  work.     In  some  cases  it  is 


598 


EETROVERSIOlSr    OF    THE    UTERUS. 


necessary  to  begin  by  removing  or  lessening  local  congestion  or  in- 
flammation. This  is  done  by  rest,  by  the  application  of  leeches,  but 
this  is  not  often  necessary;  by  sedative  pessaries;  by  the  use  of  poul- 
tices if  the  pain  is  great ;  by  saline  and  sedative  medicines.  The  me- 
chanical treatment  consists  in  the  use  of  the  sound  and  pessaries.  The 
sound  already  used  for  diagnostic  purposes  is  now  applied  to  treat- 
ment. If  by  its  means  the  uterus  be  replaced  just  before  a  menstrual 
period,  and  the  patient  be  kept  at  rest,  it  is  possible  that  the  proper 
position  may  be  maintained  throughout  the  period.  Should  this  hap- 
pen, the  period  will  pass  off  more  easily,  and  a  step  will  be  gained  to- 
wards cure.  The  uterus  will  escape  an  increment  of  excessive  conges- 
tion; and  it  may  soon  be  able  to  bear  the  contact  of  a  pessary.     The 

Fig.  126. 


Illustrating  the  mode  of  applying  the  Hodge  or  lever  pessary  for  retroflexion. 
The  diagram  represents  the  first  stage  of  introduction.    The  pessary  is  passed  edgewise  in  the  line 
of  the  vulvar  fissure.    During  its  passage  the  perineum  is  held  back  by  the  finger,  and  the  pessary  is 
pressed  backwards  so  as  to  avoid  the  symphysis. 


best  form  of  pessary  is  one  of  Hodge's.  The  size  is  selected  according 
to  the  capacity  of  the  vagina,  bearing  in  mind  the  rule  that  it  must  not 
be  so  large  as  to  stretch  the  canal.  Its  upper  limb  must  rise  to  fill  the 
cal-de-sac  behind  the  vaginal-portion,  whilst  the  lower  limb  rests  upon 


TREATMENT, 


599 


the  anterior  wall  of  the  vagina,  not  descending  below  the  middle  of  the 
symphysis  pubis.  Immediately  before  applying  the  pessary  it  is  de- 
sirable, although  not  necessary,  to  restore  the  uterus  by  the  sound  or 
finger.  One  great  test  of  the  fitness  of  the  pessary  consists  in  its  being 
borne  without  pain.  If  it  cause  pain,  it  must  without  hesitation  be 
withdrawn,  and,  guided  by  the  information  obtained  by  the  failure,  we 
select  another  pessary. 

If  the  pessary  fits  well,  the  patient  needs  no  longer  to  be  confined 
to  the  recumbent  posture.  It  is  not  the  least  of  the  many  useful  points 
of  this  admirable  instrument,  that  its  beneficial  action  is  even  promoted 


Fig.  127. 


The  second  stage  in  the  application  of  the  Hodge  pessary. 

The  pessary  has  been  turned  in  the  transverse  diameter  of  the  pelvis  after  clearing  the  vulva.    The 

upper  limb  runs  up  in  front  of  the  cervix  uteri. 

by  moderate  exercise.  In  the  upright  posture  the  inspiratory  eifort 
carries  down  the  anterior  Avail  of  the  vagina,  and  with  this,  the  lower 
limb  of  the  lever;  the  upper  limb  rises  and  comes  forward,  gently 
pushing  the  body  of  the  uterus  before  it ;  the  long  axis  of  the  lever 
under  these  circumstances  oscillates  lightly  a  little  on  either  side  of  the 


600 


RETROVERSION    OF    THE    UTERUS. 


vertical  line;  every  movement,  every  respiration,  carrying  the  fundus 
of  the  uterus  towards  its  natural  inclination. 

Gradually,  under  the  influence  of  this  support,  the  tumefaction  of 
the  body  of  the  uterus  diminishes,  and  witli  it  the  tendency  to  fall  over 
backwards;  the  vagina  and  other  supports,  relieved  of  undue  strain, 
recover  their  tone ;  and,  by  and  by,  the  pessary  can  be  dispensed  with. 

Fig.  128. 


Showing  the  third  and  final  .stage  of  the  application  of  the  Hodge  pessary. 
The  upper  limh  has  been  carried  by  the  finger  behind  the  cervix ;  the  lower  limb  lies  behind  the 
symphysis  pubis,    a  shows  the  ordinary  po.sition  of  the  pessary  during  expiration  ;  the  dotted  pes- 
sary B  shows  the  retreat  of  the  lower  limb  during  inspiration. 


This  is  the  essential  principle  of  treatment ;  but  certain  accessory 
means  are  often  useful.  Morbid  complications,  local  or  general,  must 
be  dealt  with  according  to  their  indications.  Since  not  uncommonly 
there  exists  some  engorgement  with  abrasion  of  the  vaginal-])ortion, 
and  catarrh  of  the  cervico-uterine  cavity,  an  occasional  touch  of  nitrate 
of  silver  or  the  introduction  of  a  small  stick  of  sulphate  of  zinc  will 
much  accelerate  the  cure.  Astringent  vaginal  injections  will  also  be 
useful. 

An  important  point  is  to  obviate  constipation  and  accumulation  of 
fsBces. 


RETROFLEXION     OF    THE    UTERUS.  601 

The  management  of  the  slowly  produced  form  of  retroversion 
merges  in  that  of  prolapsus,  and  does  not  differ  materially  from  that 
previously  described. 

When  adhesions  bind  down  the  retroverted  body  of  the  utei'us,  the 
use  of  the  sound  to  rectify  the  malposition  must  be  omitted.  But  the 
lever  pessary  will  still  be  useful.  It  will  sometimes  be  necessary  to 
use  in  the  first  instance  a  smaller  pessary.  The  adhesions  will  gener- 
ally slowly  stretch  under  the  continuous  gradual  action  of  the  lever; 
and  there  is  reason  to  believe  that  this  gradual  elongation  ultimately 
induces  atrophy  and  disappearance  of  the  adhesions.  Pregnancy  will 
sometimes  in  like  manner  stretch  and  induce  atrophy  of  the  adhesions. 
If  not,  by  hindering  the  develoj^ment  of  the  uterus,  they  may  cause 
abortion. 

Probably  few  cases  of  retroversion  uncomplicated  by  tumors  in  the 
walls  of  the  uterus,  or  not  caused  by  the  pressure  of  tumors  outside, 
would  long  resist  treatment,  if  we  could  exclude  counteracting  acci- 
dents. But  it  is  difficult  to  command  all  the  conditions  of  success ; 
especially  the  securing  functional  rest  of  the  organs  aifected,  the  post- 
ponement of  pregnancy,  the  avoidance  of  excessive  bodily  exercise,  and 
other  disturbing  causes. 

Retroflexion  consists  in  an  arching  of  the  uterus  backwards.  It  is 
important  to  distinguish  two  forms :  the  primary,  or  congenital ;  and 
the  secondary,  or  acquired.  The  'primary  cases  may  be  often  dis- 
covered in  the  early  years  of  menstrual  life.  They  in  no  way  depend 
upon  pregnancy.  They  are  found  in  the  virginal  state.  The  rational 
clinical  inference  is  that  the  flexion  existed  during  childhood.  During 
this  period,  the  uterus,  having  no  functional  existence,  lies  small,  un- 
developed, passive,  and  gives  rise  to  no  subjective  symptoms.  But 
when  the  organ  becomes  subject  to  the  periodical  hypersemia  of  men- 
struation, the  obstacle  set  by  this  malformation  gives  rise  to  dysmenor- 
rhoea.  And  the  body  of  the  uterus  being  enlarged  by  the  development 
incident  to  its  entry  upon  functional  activity,  and  also  abnormally  by 
the  congestions  to  which  it  is  exposed,  and  the  impediment  offered  to 
its  circulation,  becomes  the  source  of  other  troubles  which  cannot  be 
overlooked. 

Still,  although  I  believe  something  beyond  the  normal  degree  of  en- 
largement generally  takes  place  after  the  onset  of  menstrual  life,  this 
primary  form  of  retroflexion  is  rarely  marked  by  such  considerable 
enlargements  of  the  body  of  the  uterus  as  are  commonly  observed  in 
the  acquired  forms  which  ensue  upon  childbed. 

When  women  having  a  retroflected  uterus  marry,  their  suffering 
commonly  becomes  aggravated.  A  new  source  of  congestion  is  added 
to  the  menstrual  flux ;  the  organ  fails  to  get  the  intervals  of  rest  it 
needs ;  a  state  of  persistent  hypersemia  is  induced,  which  borders  on 
inflammation ;  this  easily  leads  to  hyperplasia,  and  hence  to  hyper- 
trophy of  the  body  of  the  uterus.  Its  functions  are  performed  with 
increasing  difficulty.  The  dysraenorrhcea  is  more  severe;  menorrhagia 
is  not  uncommon;  and  dyspareunia  is  almost  constant.  This  last  effect 
often  entails  another — sterility.  But  sterility  in  association  with  retro- 
flexion is  more  commonly  due  to  the  frequent  complication  with  a  nar- 


602  KETROFLEXION    OF    THE    UTERUS. 

row  OS  externum.     This  complication  also  aggravates  the  other  evils, 
especially  the  dysmenorrhoea. 

The  secondary  or  acquired  form  of  retroflexion  most  commonly  arises 
after  childbirth  or  abortion.  Labors  attended  by  exhausting  condi- 
tions, as  hemorrhage,  dispose  especially  to  this  displacement.  The 
retroflexion  often  takes  place  within  a  few  days  of  labor.  At  this 
time  its  tissues  are  soft,  flabby,  pliable ;  the  bulk  of  the  uterus,  es- 
pecially of  its  body,  is  greatly  above  the  normal  size ;  its  weight  is 
greater ;  and  as  the  increased  weight  is  put  upon  a  larger  body,  that 
is,  upon  a  longer  lever,  it  easily  falls  over,  bending  at  the  junction  of 
body  and  neck,  below  which  point  the  neck  is  fixed  and  supported  by 
its  attachment  to  the  bladder.  In  some  cases  there  is  a  predisposition 
to  retroflexion  from  this  condition  having  existed  before  the  pregnancy. 
But  in  many  cases  it  takes  place  where  no  predisposing  cause  can  be 
traced.  It  is  produced  by  pressure  acting  upon  the  enlarged  heavy 
jflaccid  uterus.  If  undue  pressure  is  exerted  within  the  first  few  days 
after  labor,  before  the  uterine  walls  have  undergone  marked  shrinking 
and  have  recovered  a  fair  degree  of  firmness  from  contraction  and  in- 
volution, retroversion  or  retroflexion  is  almost  sure  to  follow.  If 
involution  have  advanced  a  little,  so  that  the  bulk  of  the  uterus  is  sen- 
sibly diminished  and  the  rigidity  of  its  walls  is  increased,  prolapsus  is 
more  likely  to  occur  than  flexion.  I  have  said  that  flooding  disposes 
to  retroflexion  by  weakening  tissue.  It  does  so  in  still  another  way. 
A  little  blood  or  a  clot  is  often  retained  in  the  uterine  cavity ;  this 
keeps  up  excessive  bulk  of  the  organ  and  retards  involution ;  the  ex- 
pulsive eiforts  excited  by  the  presence  of  clots  bring  the  pressure  of  the 
abdominal  muscles  to  bear  upon  the  body  of  the  uterus,  and  this  is 
rolled  over.  Retroflexion,  in  its  turn,  keeps  up  secondary  puerperal 
hemorrhage,  and  thus  each  evil  aggravates  the  other. 

Professor  Martin,  of  Berlin,  has  described  and  figured^  two  cases, 
one  of  anteflexion,  one  of  retroflexion,  in  which  the  flexion  was  due  to 
defective  involution  of  the  placental  site.  The  effect  of  this  condition 
is,  supposing  the  placenta  to  have  grown  to  the  anterior  wall  of  the 
uterus,  to  keep  this  wall  longer  than  the  posterior;  this  excess  of  length 
of  the  anterior  wall  causes  the  fundus  to  roll  over  backwards,  and  thus 
retroflexion  is  produced.  Defective  involution  of  the  posterior  wall 
causes  anteflexion. 

Flexions  are  also  caused  by  tumors  in  the  fundus  uteri,  by  pressure 
of  tumors  external  to  it — as  ovarian,  by  pseudo-membranous  adhesions. 

Retroflexion  may  long  persist  as  simple  bending  or  arching;  but 
gradually,  although  seldom,  it  proceeds  to  angulation,  assuming  the 
form  of  a  broken  stick. 

The  angulation  occurs  at  the  point  of  extreme  arching,  and  this  cor- 
responds more  or  less  closely  to  the  os  internum  uteri.  Occasionally 
it  occurs  in  the  cervix  itself,  about  the  middle,  between  the  os  internum 
and  OS  externum. 

Sometimes,  says  Rokitansky,  retroflexion  passes  into  retroversion. 

1  Enstehung  von  Ante-  und  Retroflexion  der  Gebiirmutter  durch  niangelhafte 
RiickVjildiing  der  Placentiilstelle,  Beitrage  z.  Gyniikol..  1872. 


FORMS. 


603 


■The  cervix  follows  the  bending  back  of  the  body,  whilst  it  is  drawn 
upwards.  In  moderate  retroflexions,  there  is  observed  an  inclination 
of  the  vaginal-portion  forwards  and  upwards,  so  that  the  anterior  lip 
seems  flattened ;  and  as  the  flexion  increased,  the  duplicature  which 
constitutes  it  vanishes.  I  do  not  know  how  far  this  description  is 
drawn  from  clinical  observation  on  the  living.  I  am  not  myself  in  a 
position  to  afiirm  its  accuracy.  Sometimes  the  bending  is  so  great  that 
the  fundus  comes  down  to  the  level  of  the  os,  as  in  Fig.  129,  which 
represents  a  preparation  in  the  Middlesex  Hospital. 

This  preparation  also  demonstrates  a  very  important  point  in  the 
.pathology  of  retroflexion.  It  shows  that  atrophy,  or  wasting  of  tissue 
at  the  seat  of  flexion,  is  not  a  necessary  condition.  In  this  preparation 
the  inferior  wall  is  everywhere  as  thick  as  in  the  natural  state.  I  am 
convinced  that  this  is  very  frequently,  if  not,  indeed,  most  commonly, 
the  case.  Clinical  observation  satisfies  me  that  on  rectification  of  the 
position  by  the  sound  or  a  Hodge's  pessary,  the  walls  of  the  uterus 
commonly  present  their  normal  thickness. 

Still  another  point  in  the  history  of  retroflexion  is  exhibited  in  this 
preparation.  It  shows  that  the  walls  of  the  uterine  canal  have  grown 
together,  producing  atresia  in  the  neighborhood  of  the  os  uteri  internum. 


Fig.  129. 


Extreme  retroflexion  of  the  uterus.    (From  Nature,  from  a  specimen  in  Middlesex  Hospital  Museum.) 
A  section  is  made  through  the  centre,  showing  atresia  in  places  of  the  canal  of  the  uterus. 


Rokitansky  and  Virchow  both  describe  this  atrophy  and  narrowing 
at  the  point  of  extreme  flexion,  but  interpret  it  diiferently.  Rokitansky 
says  the  mucous  membrane  of  the  cervix  is  normally  thick  and  strong, 
becoming  gradually  thinner  towards  the  body  of  the  uterus.  The  seat 
of  inflexion,  he  says,  is  always  the  neighborhood  of  the  internal  os. 
He  finds  the  connective  tissue  at  this  spot  thinner  and  looser,  and  says 
this  is  the  result  of  catarrh  of  the  uterus  after  labor.  Virchow  points 
out  that  the  whole  cervix,  excepting  the  portio-vaginalis,  is  united  by 
connective  tissue  to  surrounding  parts,  especially  to  the  hinder  and 
under  surface  of  the  bladder.     The  cervix  thus  fixed,  inflexions  are 


604  EETROFLEXION    OF    THE     UTERUS. 

produced  by  inflammatory  adhesioDS  dragging  upon  the  body  of  the 
uterus.  Thus,  Kokitansky  thinks  the  atrophy  of  the  internal  orifice 
is  primary;  Virchow  thinks  it  secondary.  Clinical  observation  proves 
that  in  the  majority  of  instances,  at  any  rate,  there  are  no  adhesions. 
The  fundus  can  generally  be  lifted  up  to  its  normal  position  by  revers- 
ing the  sound.  Again,  the  frequency  of  cure  under  the  use  of  Hodge's 
pessary,  proves  the  same  tiling.  Nor  can  it  be  admitted  that  Roki- 
tansky's  theory  is  more  than  occasionally  true.  Retroflexion  is  un- 
doubtedly frequently  first  observed  to  follow  labor  immediately,  that 
is,  before  uterine  catarrh  can  have  set  in.  The  mechanism  in  these 
cases  is  simply  this :  the  heavy  fundus,  being  in  a  flaccid  state,  falls  . 
back,  partly  by  its  gravity,  partly  by  being  forced  down  under  the 
pressure  of  the  intestines.  In  such  cases,  involution  becoming  impeded, 
catarrh  will  almost  always  ensue,  and  from  long-continued  angulation, 
the  tissues  at  the  seat  of  flexion  will  undergo  some  amount  of  atrophy. 
It  is  this  altered  state  of  the  tissues  of  the  cervix,  combined  with  the 
increased  weight  and  bulk  of  the  fundus,  that  makes  restoration  to  the 
normal  position  so  diflicult  and  tedious  in  some  cases. 

Retroflexion  is  far  more  frequent  than  retroversion,  that  is,  than 
retroversion  independent  of  prolapsus.  Pathological  deductions  drawn 
from  statistics  are  exposed  to  such  numerous  fallacies  which  no  sacrifice 
of  time  and  toil  can  obviate,  that  I  do  not  attempt  to  give  any  numerical 
estimate  of  the  frequency  of  the  occurrence  of  retroflexion.  It  is  enough 
to  say  that,  in  any  given  large  number  of  women  complaining  of  pelvic 
distress,  a  considerable  proportion  will  be  found  to  have  retroflexion. 
It  is  a  frequent  cause  of  dysmenorrhoea,  menorrhagia,  uterine  hemor- 
rhage, leucorrhoea,  abortion  ;  and  this  is  not  a  contradiction  of  sterility. 
It  produces  also  distress  by  pressure  on  surrounding  parts.  The  mass 
consisting  of  the  enlarged  bent-back  uterus  protrudes  into  the  cavity 
of  the  rectum,  and  obstructs  it  like  a  ball-valve.  The  stools  become 
flattened  or  ribbon-like.  It  is  true  the  cases  are  rare  in  which  anything 
like  absolute  closure  of  the  rectum  by  approximation  of  its  walls  occurs. 
But  a  close  degree  of  occlusion  is  not  necessary  to  cause  great  disturb- 
ance of  the  function  of  the  rectum.  The  effect  of  a  foreign  body 
constantly  protruding  into  the  intestine  is  something  more  than  is 
accounted  for  by  mere  contraction  of  its  calibre.  The  constant  irri- 
tation disturbs  or  perverts  the  normal  action  of  the  muscular  coat. 
The  pain  felt  in  defecation  induces  the  sufferer  to  postpone  the  execu- 
tion of  this  necessary  act;  hence  there  arise  gradual  accumulation  of 
faeces,  and  a  habit  of  constipation  ;  these  in  time  induce  permanent 
distension  of  the  canal,  and  a  loss  of  peristaltic  power,  Avhich  may 
fairly  be  considered  as  a  degree  of  intestinal  paralysis.  If  defecation 
produce  these  results,  a  retrograde  obstruction  and  disturbance  of  the 
whole  digestive  functions  is  sure  to  follow.  Retention  of  the  residue 
of  the  food  in  the  large  intestines  leads  to  decomposition  ;  hence  flatu- 
lence and  absorption  of  some  of  the  elements  of  this  decomposition. 
The  effect  of  this  form  of  blood-poisoning,  to  which  the  term  "  co- 
prsemia"  may  not  improperly  be  applied,  is  seen  in  the  sallow,  dirty 
hue  of  the  skin,  and  the  unpleasant  exhalations  from  it.  Ascend- 
ing the  course  of  the  alimentary  canal,  the   difficulty  presented  below 


SYMPTOMS.  606 

leads  to  difficult  and  imperfect  performance  of  the  functions  of  the 
small  intestine  and  stomach ;  hence  fermentation,  flatulence,  pyrosis, 
nausea,  and  the  various  phenomena  grouped  under  dyspepsia.  The  liver 
will  hardly  escape,  especially  when,  as  is  frequently  the  case  in  women  of 
extreme  nervous  susceptibility,  vomiting  is  induced.  Imperfect  diges- 
tion has  for  its  inevitable  consequence  imperfect  nutrition  and  disordered 
secretions.  And  thus  it  happens  that  in  time  no  organ  is  left  unimpaired, 
no  function  is  healthily  performed.  The  nervous  system,  often  so 
susceptible  in  women,  will  exhibit  the  most  marked  aberrations.  The 
nervous  centres  resj)ond  to  the  slightest  impressions.  Hysteria  breaks 
out  in  all  its  manifold  eccentricities ;  neuralgia  appears  in  one  or  more 
of  its  various  forms,  as  sciatica,  lumbago,  tic  douloureux,  rheumatism ; 
headache  and  a  disposition  to  vertigo  or  syncope  frequently  recur ;  emo- 
tional, moral  and  intellectual  disturbance,  as  manifested  in  irritability, 
des]3ondency,  melancholy,  loss  of  command  over  feeling  and  thought, 
are  often  developed.  Many  of  these  phenomena  may  be  thus  traced 
to  bad  nutrition  ;  but  there  is  good  reason  to  believe  that  some,  especially 
the  nervous  phenomena,  are  more  directly  induced,  or  are  at  any  rate 
aggravated  by  the  influence  of  the  displaced  uterus  upon  the  nervous 
centres.  The  congested  displaced  organ  is  a  constant  source  of  nervous 
irritation  and  exhaustion ;  it  is  constantly  pressing  upon  the  sacral 
plexus;  it  is  constantly  sending  painful  impressions  to  the  nervous 
centres ;  constantly  using  up  in  a  morbid  direction  the  nerve-force 
which  is  wanted  for  the  performance  of  healthy  function.  A  not  un- 
common form  of  nervous  disorder  induced  by  retroflexion  is  severe, 
almost  persistent  pain  in  the  lower  part  of  the  spine;  sometimes  most 
intense  in  one  fixed  spot,  where  it  is  easy  to  evoke  the  sense  of  tender- 
ness on  pressure.  Many  such  cases  have  been  treated  as  suiferers  from 
spinal  disease,  and  have  been  confined  to  the  couch  wearing  various 
spinal  instruments  for  months  and  years,  under  the  erroneous  belief 
that  the  spinal  suffering  M^as  primary  and  essential;  its  mere  sympto- 
matic character  not  being  suspected.  With  or  without  this  marked 
spinal  pain,  a  sense  of  numbness,  of  want  of  power,  especially  of  ina- 
bility to  walk,  are  often  complained  of,  and  tend  to  confirm  the  belief 
in  spinal  disease.  A  state  of  mental  depression,  bordering  at  times  on 
despondency  and  even  melancholy,  is  a  not  uncommon  attendant  upon 
retroflexion.  The  symptoms  of  retroflexion  in  this  respect  resemble 
those  produced  by  fistula  in  ano.  I  have  often  seen  these  nervous 
symptoms  disappear  when  the  M'omb  was  restored. 

I  can  well  imagine  the  surprise  which  the  attribution  of  these 
formidable  consequences  to  retroflexion  of  the  womb  will  excite  in  the 
minds  of  those  physicians  who  are  ignorant  of  the  pathology  of  the 
pelvic  organs.  Such,  they  will  perhaps  exclaim,  are  the  extravagances 
of  specialists.  Yet,  I  would  ask,  is  not  the  sequence  of  events  as  nar- 
rated quite  in  harmony  with  sound  physiology  and  pathology  ?  lam 
very  sure  they  are  in  harmony  with  accurute  clinical  observation.  If 
this  be  doubted  by  those  who  are  ignorant  of  gynsecology,  may  it  not 
be  because  they  have  thought  it  possible  to  study  successfully  disease 
in  women,  whilst  omitting  to  take  note  of  the  diseases  of  those  organs 
which  make  her  what  she  is  ? 


606  RETROFLEXION    OF    THE    UTERUS, 

The  test  of  treatment  confirms  the  conclusion  drawn  from  diagnostic 
exploration.  In  the  great  majority  of  cases  the  evils  enumerated  as 
found  in  association  with  retroflexion  are  relieved  and  finally  removed 
when  the  retroflexion  and  its  local  consequences  are  cured. 

I  hope  to  be  pardoned  for  the  following  reflection.  Uterine  diseases, 
being  surgical  rather  than  medical,  exact  for  their  successful  treatment 
more  rigorous  precision  in  diagnosis  than  is  necessary  in  the  diseases  of 
most  other  organs.  The  principles  of  treatment  of  most  diseases  of  the 
brain,  heart,  lungs,  and  abdominal  viscera  are  really  few.  They  consist 
mainly  in  rest,  hygienic  management,  diet,  and  a  limited  use  of  medi- 
cines. I  think  it  may  be  laid  down  as  an  aphorism  that  most  acute 
diseases  not  requiring  surgical  treatment  are  subdued  by  time,  aided 
by  rest,  judicious  regimen,  salines  and  sedatives.  Where  diagnosis  of 
different  diseases  results  in  the  same  treatment,  refinement  in  diagnosis 
becomes  rather  a  matter  of  scientific  interest  than  of  concern  to  the 
patient.  Although  it  may  grate  a  little  on  the  pure  medical  ear  to 
hear  the  case  bluntly  stated,  it  is  nevertheless  true  that  the  rule  is  very 
generally  acted  upon  in  practice.  It  is  superfluous  to  point  out  that 
this  indifferentism  in  treatment  will  not  do  in  surgery.  It  will  not 
do  to  go  on  giving  salines,  alkalies,  and  sedatives,  or  placebos  to  a 
man  who  has  a  stone  in  the  bladder  that  w^ants  crushing  or  removing. 
Nor  will  it  do  to  trust  to  salines,  sedatives,  or  tonics  when  there  is  a 
dislocation  of  the  womb  that  wants  rectification. 

The  persistence  of  flexion  induces  certain  changes  in  the  uterus. 
Obstruction  to  its  circulation  brings  congestion  ;  this  leads  to  hyper- 
plasia and  hypertrophy  of  its  walls,  especially  of  the  body,  the  vaginal- 
portion  often  partaking  only  slightly  in  this  change.  The  obstruction 
to  the  escape  of  menstrual  and  mucous  secretions  from  the  cavity  of  the 
uterus  increases  the  congestion  and  leads  to  increased  secretion  ;  these 
being  retained,  uterine  contractions  are  excited  to  expel  them ;  the  os 
internum  being  more  or  less  closed,  the  uterus  contracting  as  a  sphere 
upon  its  contents,  these  tend  to  escape  equally  in  all  directions,  and 
hence  pressure  is  brought  to  bear  upon  the  openings  of  the  Fallopian 
tubes  as  well  as  upon  the  os  internum.  There  is  then,  in  proportion 
to  the  extent  of  the  obstacle  opposed  in  the  os  internum,  dilating  force 
applied  to  the  mouths  of  the  tubes;  these  gradually  yield,  and  a  retro- 
grade dilatation  of  the  tubes  sometimes  will  follow.  The  dilatation  of 
the  cavity  of  the  retroflected  uterus  is  always  attended  by  some  amount 
of  chronic  inflammation  of  the  mucous  membrane  or  catarrh.  Perhaps 
the  term  inflammation  is  ill-chosen  ;  the  condition  is  rather  one  of  con- 
stant engorgement  leading  to  rapid  shedding  of  epithelium  and  mucous 
secretion  ;  it  is  analogous  to  chronic  catarrh  of  the  lungs.  The  occa- 
sional retention  of  mucus  in  the  uterus  sets  up  colic.  A  certain  quan- 
tity of  mucus  must  accumulate  before  the  uterus  becomes  so  distended 
as  to  excite  it  to  contract ;  this  quantity  in  many  women  is  remarkably 
definite,  taking  in  some  a  week,  in  others  a  fortnight  to  collect.  Why 
the  expulsive  colic  simulating  dysmenorrhoea  occurs  midway  between 
two  periods  is  simply  because  the  uterus  being  emptied  at  the  menstrual 
epoch,  the  secretions  begin  to  gather  again  from  that  time.  Not  seldom 
a  little  blood  is  mixed  with  the  mucus.     This  is  not  to  be  interpreted 


CONSEQUENCES. 


607 


as  the  result  of  ovulation,  but  is  simply  hemorrhagic,  the  product  of 
engorgement.  It  is  a  common  history  to  hear  from  women  suffering 
from  uterine  obstruction,  whether  from  retroflexion  or  other  cause,  that 
they  have  periodical  gatherings  like  an  abscess  in  the  womb  attended 
by  severe  colic  and  expulsive  pains  which  are  relieved  by  the  "bursting" 
and  escape  of  a  quantity  of  discharge.  These  cases  are  of  the  kind  above 
described,  although  they  may  not  exhibit  equally  regular  periodicity. 

Serious  dangers  attend  retroflexion  from  the  persistence  of  this  con- 
dition after  conception  has  taken  place.  The  unfavorable  shape  of  the 
uterus,  and  its  retention  in  the  pelvis,  oppose  the  due  development  of 
the  organ.  Hence  frequently  abortion  ensues ;  and  when  this  does  not 
happen,  there  is  the  more  formidable  danger  arising  from  the  locking 
of  the  enlarged  uterus  in  the  pelvis  about  the  third  or  fourth  month. 


Fig.  130. 


Illustrating  the  diagnosis  of  retroflexion  by  the  vaginal  touch. 

The  history  of  this  accident  is  fully  described  in  my  "Obstetric  Ope- 
rations." These  probable  events  strongly  enforce  the  expediency  of 
curing  retroflexion. 

The  flexions  found  in  advanced  life,  may  be  the  persistent  flexions 
from  an  earlier  age.     But  some  undoubtedly  take  their  origin  after  the 


608  RETROFLEXION    OF    THE    UTERUS. 

climacteric  period.  The  body  of  the  uterus,  which  has  failed  to  undergo 
the  normal  senile  retrogression  or  atrophy,  is  pulpy,  traversed  by  degen- 
erating vessels,  it  is  softer  and  thinner;  its  cavity  is  dilated,  filled  with 
catarrhal  secretion ;  its  cervix  is  beset  in  its  connective-tissue  substra- 
tum with  N^abothian  vesicles,  and  often  from  the  persistent  production 
of  these  bodies  it  is  atrophied  and  degenerated  to  a  mere  framework 
from  their  dehiscence  in  the  tissue.  This  condition  is  principally  found 
at  the  seat  of  the  os  internum;  indeed,  here  it  has  often  proceeded  to  a 
scar-like  retraction  of  the  atrophied  connective  tissue,  amounting  to 
atresia.  This  is  seen  in  Fig.  129.  At  this  spot  the  uterine  body  some- 
times bends  in  the  shape  of  a  fracture :  it  may  be  backwards  or  forwards. 
In  other  cases,  not  uncommon,  the  flexion  causes  retention  of  the  cat- 
arrhal mucus",  which  induces  severe  uterine  colic,  and  pain  radiating  in 
the  pelvis,  and  leading  to  serious  nervous  prostration. 

The  diagnosis  of  retroflexion  differs  in  some  degree  from  that  of 
retroversion.  The  os  uteri,  instead  of  pointing  forwards  near  the  sym- 
physis pubis,  points  more  or  less  downwards,  and  is  near  the  middle  of 
the  pelvic  cavity.  The  position  and  direction  of  the  os  uteri  being 
determined,  the  exploring  finger  feels  in  front  of  the  vaginal-portion, 
seeking  to  trace  the  cervix  and  body  of  the  uterus  forwards  through 
the  anterior  I'oof  of  the  vagina,  the  normal  seat  of  the  organ.  Instead 
of  feeling  it  here,  the  finger  misses  the  resistance  of  solidity,  and  by 
combining  abdominal  palpation,  the  two  hands  may  be  brought  to 
approach  each  other,  w^hen  the  absence  of  the  uterus  from  its  natural 
place  is  determined.  The  exploring  finger  next  feels  on  either  side, 
and  determines  the  condition  of  this  part  of  the  roof  of  the  vagina. 
It  is  then  carried  behind  the  vaginal-portion  and  feels  a  firm  globular 
uniform  mass  through  the  posterior  wall  of  the  vagina.  Tracing 
this  on  to  the  vaginal-portion,  the  tip  of  the  finger  sinks  into  a  groove 
between  the  two.  It  is  generally  possible  to  determine  the  continuity 
of  these  two  parts.  This  is  best  done  by  keeping  the  finger  behind 
the  vaginal-portion  so  as  to  feel  the  body  of  the  uterus,  then  to  com- 
bine the  abdominal  touch  so  as  to  embrace  the  cervix  between  the  two 
hands.  Movement  imparted  by  one  to  the  body  between  will  be  felt 
by  the  other. 

This  is  made  clearer  still  by  the  rectal  touch.  The  finger  in  the 
rectum  will  travel  round  the  outline  of  the  post-cervical  tumor  to  a 
greater  extent  than  can  the  finger  in  the  vagina.  The  abdominal 
touch  combined  with  the  rectal  also  affords  more  positive  evidence  than 
the  abdomino-vaginal  touch. 

The  experimentmn  crucis,  however,  is  performed  with  the  sound. 
Before  passing  it  the  probability  of  pregnancy  must  be  carefully 
weighed.  In  the  great  majority  of  single  persons,  and  of  those  who 
have  lived  a  married  life  for  several  years  without  having  children,  the 
probability  is  strongly  in  the  negative.  The  presumption  is  also  in 
the  negative  in  those  who,  having  had  children,  seek  relief  from  the 
consequences  of  retroflexion.  Amongst  these  consequences  frequently 
is  acquired  sterility.  Two  things  help  in  forming  an  ojiinion  :  the 
date  of  the  last  menstruation,  and  the  bulk  of  the  uterus.  If  the  bulk 
be  sensibly  increased,  and  a  period  have  been  missed,  of  course  the 


DIAGNOSIS. 


609 


sound  should  not  be  used.  It  should  not,  however,  be  forgotten  that 
increased  bulk  of  the  uterus  is  an  almost  constant  attendant  upon  re- 
troflexion. To  pass  the  sonnd  a  curve  is  given  to  it  corresponding  to 
the  idea  formed  of  the  degree  of  retroflexion.     (See  Fig.  131.)     For 


Diagnosis  and  reposition  of  the  retroiiected  uterus  by  tlie  sound. 
A.  The  uterus  in  retroflexion,  the  sound  in  its  cavity,    b.  The  uterus  brought  forward  by  revers. 
ing  the  sound.    The  fundus  can  now  be  felt  by  fingers  pressing  in  the  abdominal  wall  above  the 
symphysis. 

example,  if  the  mass  supposed  to  be  the  fundus  of  the  uterus  falls 
below  the  level  of  the  cervix,  and  the  angle  or  groove  behind  the  cervix 
be  very  marked,  the  curve  given  to  the  sound  must  be  considerable. 
But  in  the  majority  of  instances  a  moderate  curve  will  be  enough. 
By  a  little  manoeuvre,  by  lifting  up  the  fundus  by  the  finger  whilst  the 
point  of  the  sound  is  passing  the  os  internum,  the  seat  of  chief  flexion, 
the  whole  organ  is  somewhat  straightened.  This  wonderfully  facili- 
tates the  passing  of  the  sound.     The  first  stage  of  the  introduction  of 

39 


610  RETROFLEXION    OF     THE    UTERUS. 

the  sound  is  best  effected  by  passing  the  point  into  the  os  externum  as 
far  as  the  os  internum,  with  the  concavity  of  the  curve  directed  for- 
wards ;  then  the  point  should  be  turned  backwards  by  making  the 
handle  describe  a  large  circle,  thus  bringing  the  concavity  backwards. 
The  handle  is  then  carried  forsvards  whilst  the  guiding  finger  lifts  up 
the  fundus ;  the  point  then  following  the  curve  of  the  canal  penetrates 
to  the  fundus.  When  the  sound  has  gone  the  normal  length  of  two 
and  a  half  inches,  the  mobility  of  the  uterus  must  be  ascertained  by 
gently  bringing  the  point  of  the  sound  forwards  again,  so  as  to  lift  the 
fundus  and  bring  it  into  anteversion.  This  must  be  executed  gently 
lest  adhesions  exist.  It  is  also  important,  in  order  to  avoid  dragging 
the  uterus,  and  the  pressure  upon  its  internal  surface  which  a  large 
revolution  of  the  point  of  the  sound  would  cause,  to  reverse  the  sound 
by  making  the  handle  describe  a  large  revolution.  The  portion  then 
inside  the  uterus,  if  moderately  curved,  will  move  upon  its  axis  de- 
scribing a  very  small  circle,  and  consequently  turning  in  the  cavity 
without  exerting  any  injurious  pressure.  In  short  the  uterine  sound 
should  be  handled  with  the  same  gentle  touch,  and  in  a  similar  manner 
as  the  catheter  in  traversing  the  male  urethra.  The  tour-de-maitre 
practiced  in  reversing  the  catheter  to  clear  the  portion  of  the  urethra 
under  the  pubic  arch,  must  be  imitated  when  we  seek  to  bring  the 
retroflected  uterus  forward  into  anteversion. 

A  special  sound  has  been  constructed  to  bring  the  uterine  body  for- 
ward without  making  the  point  revolve.  This  consists  in  a  sound 
jointed  at  two  and  a  half  inches  from  its  point,  which  allows  the 
uterine  part  to  be  set  at  any  angle  for  introduction,  and  which  can 
then  be  brought  forward  by  working  a  screw  in  the  handle.  I  am 
not  partial  to  complicated  instruments  in  which  machinery  is  made  to 
do  what  the  sentient  hands  should  do. 

When  restoration  is  accomplished  the  demonstration  is  complete. 
There  is  no  room  for  ambiguity.  The  tumor  behind  the  cervix  has 
disappeared ;  it  has  been  brought  forward  to  the  normal  place  of  the 
body  of  the  uterus.  Supported  on  the  sound  it  can  now  be  felt  by 
the  liand  pressed  in  above  the  symphysis  pubis ;  and  the  pressure  so 
exerted  upon  it  is  felt  by  the  finger  which  keeps  watch  upon  the  vagi- 
nal-portion inside.  On  withdrawing  the  sound,  the  uterus  will  often 
for  a  time  maintain  itself  in  its  restored  position.  But  more  frequently 
its  fundus  will  roll  back  again.  If  we  get  all  this  evidence  it  is  su- 
perfluous to  discuss  what  are  the  conditions  which  might  be  mistaken 
for  retroflexion.  Nothing  but  retroflexion  will  give  the  evidence  de- 
scribed. But  it  may  not  be  possible  or  prudent  to  pass  the  sound. 
The  two  conditions  most  nearly  simulating  retroflexion  are :  a  fibroid 
tumor  in  the  posterior  wall  of  the  uterus,  and  a  retro-uterine  hiemato- 
cele.  In  both  cases  a  firm  rounded  mass  may  be  felt  behind  the  vagi- 
nal-portion separated  from  it  by  a  groove,  and  bulging  forward  the 
posterior  wall  of  the  vagina.  But  in  both  cases  the  body  of  the  uterus 
may  be  felt  by  combined  vaginal  and  abdominal  touch  above  or  be- 
hind the  symphysis  pubis.  In  the  case  of  the  retro-uterine  hemato- 
cele the  uterus  is  pressed  bodilj  forwards,  and  the  cervix  is  generally 
very  close  behind  the  symphysis  pubis.     Neither  of  these  conditions 


TREATMENT.  611 

per  se  excludes  the  sound.  If  this  be  passed,  it  is  easy  to  demonstrate 
the  position  of  the  body  of  the  uterus,  and  to  distinguish  it  from  the 
tumor  behind  the  cervix. 

The  principle  of  treatment  of  retroflexion  is  essentially  the  same  in 
all  its  forms.  One  primary  object  to  strive  for  is  to  bring  the  cervico- 
uterine  canal  as  nearly  as  possible  into  one  axis,  so  as  to  afford  free 
communication  between  the  cavity  of  the  uterus  and  the  vagina. 
When  this  is  attained  the  -distress  due  to  retention  of  blood,  clots,  or 
mucus  will  subside.  The  fulfilment  of  this  indication  further  implies 
a  considerable  rectification  of  the  position  of  the  uterus,  which  is  the 
next  object  to  strive  for.  The  uterus  can  hardly  be  made  straighter 
without  at  the  same,  time  lifting  up  the  fundus.  When  this  is  done, 
the  engorgement  of  the  body  of  the  uterus  will  diminish,  very  often 
quickly ;  as  the  bulk  lessens  there  is  a  smaller  degree  of  vicious  lever- 
age to  counteract,  so  that  the  cure  may  be  expected  to  go  on  at  an  ac- 
celerated pace.  The  combined  progress  of  rectification  and  of  diminu- 
tion of  bulk  brings  immense  relief  to  the  organs  hitherto  pressed  upon. 
The  rectum  especially,  and  the  superior  part  of  the  alimentary  canal, 
are  amongst  the  first  organs  to  benefit  by  the  change.  I  have  known 
constipation  heretofore  obstinate,  speedily  give  way  to  healthy  and  regu- 
lar action  of  the  bowels.  And  it  is  needless  to  say  that  general  ameli- 
oration soon  follows.  The  local  irritation  being  lessened,  irregular 
nervous  manifestations  tend  to  subside.  Greater  power  of  locomotion 
is  gained ;  and  what  with  freedom  from  pain  and  the  renewed  capacity 
for  exercise,  nutrition  is  often  remarkably  improved. 

A  third  indication  to  take  is  to  treat  the  local  complications,  whether 
effects  or  causes,  of  the  retroflexion.  These,  that  is,  the  engorgement, 
endo-catarrh,  and  other  changes  in  the  uterus,  will,  it  is  true,  tend  to 
subside  under  the  means  employed  to  rectify  the  malposition.  But 
their  cure  may  be  accelerated  by  treatment  ad  hoc. 

The  first  indication  and  the  second  can  hardly  be  dealt  with  sepa- 
rately. To  straighten  the  axis  of  the  uterus  and  to  restore  the  fundus 
to  its  normal  position  are  objects  attained  concurrently  by  the  same 
means.  These  means  are  mostly  mechanical.  Before  applying  these 
it  is  often  desirable  to  give  an  opportunity  for  any  excessive  engorge- 
ment or  inflammation  that  may  exist,  to  subside  under  rest  in  bed, 
perhaps  local  bleeding,  salines,  sedatives,  and  by  the  regulation  of  the 
bowels  by  gentle  aperients  and  enemata.  Admitting  the  great  impor- 
tance of  this  course  as  a  preliminary  condition  of  cure,  I  cannot  agree 
with  those  who  rely  upon  it  as  sufficient  to  cure.  I  have  indeed,  in 
not  a  few  cases,  seen  retrovei'sion  and  retroflexion  of  the  secondary 
form  relieved,  the  womb  regaining  its  position  apparently  spontane- 
ously, under  arrest  and  the  other  means  enumerated.  But  in  some,  at 
least,  of  these  the  cure  would  probably  have  been  accelerated  and 
made  more  sure  by  the  timely  recourse  to  mechanical  support.  And 
expectancy,  aided  or  not  by  these  means,  will  certainly  bring  no  recti- 
fication of  a  primary  retroflexion.  The  management  of  a  primary  re- 
troflexion will  often  differ  from  that  of  a  secondary  retroflexion  in  this: 
the  primary  retroflexion  is  often  complicated  with  a  marked  degree  of 
stenosis  of  the  os  uteri  externum.    This  is  an  additional  cause  of  obstruc- 


612  RETKOFLEXION    OF    THE    UTERUS. 

tion  and  retention,  which  rarely  exists  in  the  secondary  form.  It  is 
the  first  thing  that  requires  treatment.  The  os  externum  should  be 
enlarged,  whether  it  be  the  case  of  a  single  woman  applying  for  relief 
of  dysmenorrhoea,  or  that  of  a  married  one,  to  whose  menstrual  diffi- 
culty are  superadded  dyspareunia  and  sterility.  The  operation  is  in 
all  respects  the  same  as  that  described  under  dysmenorrhoea  from 
stenosis  of  the  os  externum.  The  os  is  divided  on  either  side  so  as  to 
give  a  free  opening  into  the  cavity  of  the  cervix.  This  in  itself  dimin- 
ishes the  down-curving  of  the  vaginal-portion,  and  independently  of 
special  means  for  straightening  the  uterus  it  virtually  straightens  its 
canal.  This  obstacle  being  removed,  the  treatment  of  the  primary  re- 
troflexion becomes  the  same  as  that  of  the  secondary  form,  excepting 
in  this,  that  there  is  more  likely  in  the  latter  form  to  be  an  inflammatory 
complication  of  the  cervix.  This  requires  special  treatment,  which 
may,  however,  go  on  concurrently  with  the  treatment  for  rectification. 

The  means  brought  forward  at  different  times  for  the  rectification  of 
the  retroflected  uterus  are  numerous.  Experience  has  eliminated  some 
as  ineffective  or  injurious,  and  has  established  the  value  of  others.  We 
need  not  dwell  upon  exploded  contrivances;  but  we  cannot  pass  by 
without  discussion  the  merits  of  intra-uterine  pessaries.  The  idea  of 
straightening  the  bent  uterus,  and  fixing  it  in  its  normal  position  by 
introducing  a  rigid  stem  into  its  canal,  was  revived,  if  not  first  conceived, 
by  the  late  Professor  Simpson.  It  was  taken  up  and  largely  tried  by 
Valleix.  Cases,  not  a  few,  are  known  in  which  death  from  metroperi- 
tonitis followed  the  use  of  instruments  of  this  kind.  The  intra-uterine 
stem  being  attached  to  an  external  support  could  hardly  be  expected 
to  be  free  from  this  danger. 

All  instruments  which  disregard  the  physiological  fact  that  the  uterus 
is  a  movable  organ  should,  I  think,  be  unhesitatingly  discarded  as 
vicious  in  principle  and  dangerous  in  practice.  All  intra-uterine  stems 
carried  on  supports  having  a  point  d'appui  outside  the  body  fall  under 
this  ban,  even  although  a  certain  amount  of  elasticity  be  introdued  into 
some  part  of  the  apparatus.  It  may  be  said,  without  injustice  to  the 
ingenuity  displayed  in  the  elaboration  of  these  contrivances,  that  they 
have  fallen  into  disuse  under  the  combined  influence  of  the  disasters 
which  attended  their  use,  and  of  the  introduction  of  better  means,  espe- 
cially of  Hodge's  lever-pessaries. 

The  objection  above  urged  does  not  apply  to  the  simple  intra-uterine 
stems  which  are  unconnected  with  external  supports,  and  which  do  not 
control  the  uterus  in  its  movements.  The  best  of  these  is  the  late  Dr. 
Wright's,  or  a  modification  of  it.  This  instrument  is  about  two  or  two 
and  a  quarter  inches  long.  When  mounted  on  its  carrier  for  the  pur- 
pose of  introduction  it  is  a  single  solid  stem.  When  introduced  and  the 
carrier  is  withdrawn,  the  stem  opens  by  the  elasticity  of  the  two  branches 
of  which  it  is  composed,  so  that  the  ends  fit  the  normal  triangular 
shape  of  the  cavity  of  the  cervix.  This  expansion  helps  to  lift  up  the 
fundus,  and  the  uterus  thus  supported  is  kept  nearly  straight.  Still 
this  will  not  always  bring  the  fundus  forwards ;  it  remains  in  retro- 
version. For  complete  restitution  we  must  rely  upon  Hodge's  lever- 
pessary.     This  will  now  operate  with  increased  advantage,  as  the  lever 


TREATMENT. 


613 


formed  by  the  uterus  upon  which  it  has  to  act  is  straighter  and  firmer. 
This  separate  mode  of"  using  the  intra-uterine  and  the  extra-uterine 
pessaries  is,  in  my  opinion,  the  safest  and  most  satisfactory  in  its  results. 


Illustrating  occasional  vicious  action  of  the  Hodge  in  extreme  retroflexion  of  the  uterus. 
The  upper  limb  gets  wedged  in  the  angle  of  flexion,  and  lifts  the  whole  organ  up  without  straight- 
ening it. 

The  mobility  of  the  parts  is  sufficiently  respected;  and  opportunity  is 
given  for  the  recovery  of  the  natural  tonicity  of  the  cervix  uteri.  I 
cannot  approve  of  those  instruments  in  which  the  intra-uterine  stem  is 
set  on  a  ball  or  ring,  or  the  crossbar  of  a  Hodge's  pessary.  This  is  a 
kind  of  impalement  which  limits  too  much  the  mobility  of  the  uterus, 
and  which  is  apt  to  cause  inflammation  of  the  uterus  or  surrounding 
tissues. 

Before  using  any  form  of  intra-uterine  pessary,  it  is  desirable  to 
ascertain  whether  the  object  cannot  be  attained  without  using  them  at 
all.  The  cases  where  it  is  necessary  to  use  them  are  exceptional.  The 
Hodge  has  happily  almost  driven  out  of  use  the  fixed  intra-uterine 
stem.  Before  applying  a  Hodge,  it  is  useful  to  bring  the  retroflected 
fundus  forward  into  its  proper  position.  We  thus  increase  the  length 
of  the  post-cervical  vaginal  cul-de-sac  and  give  room  for  the  pessary  to 
rise  well  behind  the  cervix,  a  condition  of  its  efficiency. 

In  the  majority  of  cases  a  simple  Hodge  pessary,  modified  in  shape 


614 


RETROFLEXION    OP    THE    UTERUS. 


and  size  to  suit  the  peculiarities  of  the  case,  is  the  best  instrument  to 
use.  It  may  be  worn  continuously  for  several  months,  under  occa- 
sional inspection.  Pregnancy  not  infrequently  takes  place  whilst  it  is 
worn.     Indeed,  I  have  little  doubt  that  the  action  of  the  instrument 


Fig.  133. 


Illustrating  the  combined  action  of  the  intra-uterine  pessary  and  the  Hodge. 
The  first  straightens  the  uterus,  converting  it  into  a  firm  lever,  a  b.    Then  the  second,  forming 
another  lever,  c  d,  lifts  up  the  fundus,    e  f  shows  the  leverage-movement  of  the  Hodge,  c  d.    Under 
inspiration,  E  lifts  up  the  body  of  the  uterus. 

favors  impregnation.  When  this  occurs  it  is  desirable  to  continue  the 
use  of  the  instrument  until  the  end  of  the  third  month  of  gestation, 
that  is,  until  the  fundus  of  the  uterus  has  risen  out  of  the  pelvis.  By 
this  plan  the  dangers  of  abortion  and  of  locking  of  the  uterus  in  the 
pelvis  are  greatly  lessened. 

Dr.  Peaslee  describes  a  pessary  which  acts  on  tlie  principle  of  a 
prop.  It  is  shaped  somewhat  like  Hodge's.  Its  lower  limb  is  moulded 
so  as  to  take  a  j)oint  d'appui  upon  the  inner  surface  of  the  symphysis 
pubis,  whilst  the  upper  limb,  like  Hodge's,  goes  into  the  posterior 
vaginal  cul-de-sac.  The  uterus  is  thus  literally  propped.  I  have  no 
experience  of  the  instrument.  In  so  far  as  it  is  fixed,  it  falls  under 
the  objection  which  applies  to  all  pessaries  which  do  not  respect  the 
natural  mobility  of  the  pelvic  organs. 

Dr.  Moir  has  treated  retroflexion  by  introducing  sponge  or  larainai'ia 


INVERSION    OF    THE    UTEEUS.  615 

tents.  For  the  time  these  will  straighten  the  uterus,  and  establish  free 
communication  between  its  two  cavities.  It  is  a  method  which  has  its 
uses,  but  as  these  pessaries  are  somewhat  apt  to  excite  inflammation, 
they  should  not  be  resorted  to  unless  other  means  fail ;  or  unless  they 
are  indicated  by  other  conditions,  such  as  metrorrhagia,  for  which  the 
application  of  remedies  inside  the  uterus  is  useful. 


CHAPTER  XLYI. 

INVERSION  OF  THE  UTERUS;  DEFINITION:  ACUTE  AND  CHRONIC  ; 
CAUSES,  IN  THE  PARTURIENT  AND  NON-RREGNANT  UTERUS; 
SYMPTOMS,  COURSE,  AND  TERMINATIONS ;  PROGNOSIS;  DIAG- 
NOSIS; TREATMENT. 

The  history  of  recent  inversion  of  the  uterus  belongs  especially  to 
obstetrics.  In  my  work  on  "  Obstetric  Operations,"  I  have  traced  this 
history  with  some  care.  This  of  course  includes  the  study  of  the  causes 
which  lead  to  the  greater  number  of  inversions.  A  very  large  n^ajority 
of  cases  follow  immediately  upon  labor.  But  it  is  important  to  re- 
member that  inversion  has  occurred  quite  independently  of  labor, 
although  it  seems  necessary  that  conditions  in  some  important  respects 
analogous  to  pregnancy  and  labor  should  exist.  Such,  for  example,  is 
the  case  when  a  polypus  attached  to  the  fundus  uteri  induces  develop- 
ment of  the  muscular  wall,  and  expulsive  action  being  excited,  the 
fundus  uteri  follows  the  tumor,  producing  inversion. 

Invei'sion  of  the  uterus  may  be  defined  as  a  dislocation  by  which  the 
inner  wall  of  the  uterus  is  turned  outwards ;  its  cavity  disappearing, 
and  another  cavity  forming  above,  the  inner  surface  of  which  is  the 
proper  external  covering  of  the  uterus.  This  cavity  contains  a  portion 
of  the  Fallopian  tubes  and  of  the  round  ligaments,  which  are  dragged 
in  by  the  fundus  uteri.  Even  convolutions  of  intestine  may  fall  in. 
And  in  the  recent  state  after  labor,  the  ovaries  also  may  be  drawn  in. 
But  in  the  chronic  state,  when  the  uterus  is  much  reduced  in  size,  the 
ovaries  are  found  outside  the  artificial  cavity. 

There  are  degrees  of  inversion.  The  most  simple  division  is  that 
proposed  by  Crosse  (see  Fig.  134).  1st.  Depression ;  the  fundus  or 
placental  site  falls  inwards,  projecting  in  the  cavity  of  the  uterus.  2d. 
Introversion,  or  intussusception.  So  great  a  part  of  the  fundus  falls  in 
that  it  comes  within  the  grasp  of  the  portion  of  the  uterus  into  which 
it  is  received.     In  the  extreme  form  of  this  decree  the  fundus  reaches 


616 


INVERSION    OF    THE     UTERUS. 


to  the  OS  uteri,  through  which  it  may  be  felt  like  an  intra-uterine 
polypus.  3d.  Perversion;  the  fundus  passes  through  the  os  uteri. 
There  are  degrees  of  this.  In  the  extreme  form  the  inversion  is  so 
complete  that  even  the  cervix  and  os  are  inverted. 


Illustrating  the  three  degrees  of  inversion  of  the  uterus.    (From  Crosse.) 

a.  The  inverted  fundus.    6.  The  natural  cavity,    c.  The  vagina,    d  d.  The  upper  margin  of  the  cup 

formed  by  the  inverting  fundus  uteri. 


Inversion  is  acute  or  chronie.  In  my  article  on  this  accident  in 
Samuel  Lane's  edition  of  Samuel  Cooper's  "  Surgical  Dictionary,"  I 
defined  acute  inversion  as  ending  with  the  completion  of  the  involution 
of  the  uterus.  When  this  process  is  complete,  the  case  is  chronic.  The 
distinction  is  based  upon  the  important  fact  that  whilst  involution  is 
going  on,  the  muscular  fibres  are  still  possessed  of  some  active  property, 
the  organ  is  larger,  and  the  cervix  less  rigid. 

During  this  stage  the  parts  are  more  yielding,  and  redaction  is  com- 
paratively easy.  It  is  the  chronic  form  including  cases  which  occur 
independently  of  labor  with  which  we  are  now  principally  concerned. 
But  some  reference  to  the  conditions  under  which  inversion  is  produced 
will  not  be  out  of  place. 

The  two  following  drawings  represent  the  conditions  of  chronic  in- 
version and  the  relations  of  the  several  parts. 

Fig.  136  is  reduced  from  an  original  drawing  by  M.  Biot  for  Mr. 
Crosse  (see  his  Essay).  It  represents  a  preparation  in  the  Musee 
Dupuytren  at  Paris.  The  subject  died  of  exhaustion  twenty-two 
months  after  labor. 

Causes. — The  essential  conditions  for  the  production  of  inversion 
are,  on  the  one  hand,  relaxation  of  some  part  or  tlie  whole  of  the  walls 
of  the  uterus,  and,  on  the  other,  considerable  enlargement  of  its  cavity. 
When  the  uterus  has  contracted,  its  walls  are  so  thick,  and  the  cavity 
is  so  reduced,  the  anterior  wall  being  flattened  close  in  contact  with  the 
posterior  wall,  that  inversion  cannot  take  place.  Of  this  any  one  may 
convince  himself  by  passing  his  fingers  into  the  living  uterus  during 
active  contraction,  or  by  trying  to  invert  a  uterus  out  of  the  body  which 
has  been  well  contracted. 

Adhesion  of  the  placenta  growing  from  the  fundus  is  a  frequent 
cause.    This  is  often  united  with  spastic  narrowing  of  the  lower  segment 


CAUSES. 


617 


of  the  uterus.     This  narrowing  will  generally  prevent  complete  inver- 
sion.    In  this  case  the  os  uteri  may  not  relax  until  partial  inversion 


Extreme  inversion  in  section.     (Haif-size.     From  Crosse's  Essay,  talven  from  a  specimen  of  Dr. 
Mackenzie,  of  Glasgow.) 

a.  Vagina.  6.  Fundus  uteii.  c  c.  Angles  of  inflexion,  c  c,  d  d.  Marlv  the  extent  of  the  uuinverted 
cervix,  f.  The  peritoneal  cul-de-sac  of  inverted  uterus,  g  r;.  Fallopian  tubes  passing  down  to  the 
inverted  fundus,    k  k.  Round  ligaments,    h  h.  Ovaries,    i  i.  Broad  ligaments. 

has  lasted  some  time.     When  the  os  yields,  as  it  always  will  do,  under 
sustained  pressure,  it  permits  the  tumor  formed  by  the  advancing  body 

Fig.  136. 


a.  Vagina,  h.  Inverted  fundus  incised  at  c  to  show  its  cavity,  d.  Point  of  inversion  with  round 
ligaments,  Fallopian  tubes,  and  ovarian  ligaments  drawn  in.  g  g.  Round  ligaments,  e  e.  Ovaries. 
//.  Fimbriated  extremities  of  tubes.    A.  Cervix  covered  by  peritoneum.    (Two-thirds  size.) 


618  INVERSION    OF    THE    UTERUS. 

of  the  uterus  to  pass  through.  Then  the  inversion  is  complete.  Ana- 
tomical conditions  concur  to  favor  this  process.  During  gestation  the 
ligaments  become  elongated,  and  offer  no  great  resistance  to  inversion, 
and  the  hollow  or  cup  made  by  the  inverting  outer  surface  of  the  uterus 
receives  the  broad  and  round  ligaments.  On  the  other  hand  the  con- 
nections of  the  cervix  to  its  ligaments  and  to  the  bladder  and  vagina, 
hinder  the  inversion  of  this  part  for  a  time.  Inversion  then  begins  at 
the  fundus  or  placental  site.  This  part  is  liable,  in  consequence  of  the 
placental  attachment,  to  paralysis  (Rokitansky),  and  being  thicker  than 
the  other  parts  of  the  uterine  walls,  forms  a  projection  into  the  cavity. 
That  is  the  first  step.  Then  if  the  placenta  adhere  and  be  dragged 
upon  by  the  cord  from  below,  or  if  the  diaphragm  and  abdominal  walls 
act,  as  in  a  bearing-down  effort,  the  part  already  disposed  to  fall  inwards 
is  forced  further  down  into  the  cavity.  The  external  cup-like  depres- 
sion formed  by  paralysis  of  the  placental  site  may  be  felt  by  examina- 
tion through  the  abdominal  walls  ;  and  especially  is  this  the  case  if  you 
drag  upon  the  cord,  the  placenta  adhering.  When  things  have  gone  thus 
far,  further  pressure  or  dragging  brings  the  fundus  down  upon  the 
cervix  and  os.  If  this  part  be  contracted,  it  may  prevent  the  fundus 
from  coming  through ;  or,  the  pressure  continuing,  the  os  may  yield, 
and  allow  it  to  slip  through  ;  or  the  advancing  fundus  may  find  the 
cervix  relaxed  and  oftering  no  opposition.  Indeed  the  cervix  is  very 
liable  to  temporary  paralysis  after  labor,  and  more  especially  is  this 
the  case  when,  as  is  not  uncommon,  it  is  lacerated.  Accordingly  ,it 
has  been  observed  that  some  cases  have  occurred  gradually,  others  sud- 
denly. This  explanation  represents  the  views  that  are  most  generally 
received. 

Smellie  relates  a  case  told  him  by  Lucas  of  a  woman  whose  uterus, 
after  inversion,  having  been  replaced,  was  immediately  re-inverted. 
"  It  was  like  a  piece  of  tripe."  The  uterus  has  even  been  inverted 
after  post-mortem  delivery,  under  circumstances  which  preclude  the 
idea  that  active  contraction  of  the  organ  was  an  efficient  factor.  Dr. 
Aveling  has  collected  a  series  of  cases  of  this  nature.  Hemorrhage 
again  is  known  to  be  a  disposing  cause.  Whoever  has  had  his  hand 
in  the  cavity  of  a  uterus  pow^erless  through  loss  of  blood,  who  has  felt 
its  flaccid  wall  yielding  to  every  pressure,  internal  or  external,  like 
"tripe,"  or  wet  brown  paper,  will  understand  how  easy  it  would  be  for 
such  a  uterus  to  be  inverted.  Indeed,  I  have  often  felt  partial  inver- 
sion taking  place  whilst  endeavoring  to  detach  adherent  placenta  by  the 
fingers. 

Lazzati  and  others  have  distinctly  observed  that  the  uterus  was  inert 
at  the  time  of  inversion.  Many  histories  show  that  inversion  followed 
immediately  upon  very  rapid  labors,  in  which  it  is  probable  that  the 
uterus  is  more  or  less  inert. 

In  a  most  admirable  and  complete  monograph  on  the  subject,  Mr. 
Crosse  ("  An  Essay,  Literary  and  Practical,  on  Inversio  Uteri :"  J.  G. 
Crosse,  F.R.S.,  1847)  says  the  most  powerfully  predisposing  condition 
to  the  commencement  of  inversion  [depresslo),  and  M'ithout  which  the 
greater  degrees  cannot  transpire,  is  partial  inertia.  He  also  points  out 
that  one  of  the  most  constant  conditions  is  attachment  of  the  placenta 


CAUSES.  619 

to  the  fundus  uteri.  Then,  again,  the  action  of  the  uterus  in  increas- 
ing an  inversion,  when  once  this  has  commenced,  has  been  admitted 
and  indicated  by  very  many  authorities,  but  by  none  more  pointedly 
than  by  Denman  ("Practices  of  Midwifery  "),  who  observes  that  "if  a 
disposition  to  an  inversion  be  first  given  by  the  force  used  in  pulling 
the  funis,  it  may  be  completed  by  the  action  of  the  uterus."  Crosse 
then  states  the  modern  doctrine  in  distinct  terms  :  "  I  cannot  conceive 
that  the  organ  itself  has  any  power  to  commence  the  displacement,  and 
to  cause  simple  depressio.  .  .  .  But  when  a  commencement  has  been 
made,  and  the  case  goes  on  to  introversio,  bringing  the  fundus  within 
the  grasp  and  influence  of  the  un inverted  body  of  the  uterus,  this 
organ  will,  by  the  natural  powers  called  into  action  by  its  sensibility, 
regard  the  inverted  part  as  an  extraneous  mass,  and  proceed  to  act 
upon  it  instinctively  by  successive  and  suitable  efforts  of  its  muscular 
coat,  to  propel  it  downwards;  whilst  the  os  and  cervix  will  by  consent, 
and,  as  transpires  in  the  regular  process  of  delivery,  become  dilated, 
and  thus  a  part  of  the  uterus  will  act  on  the  rest,  and  carry  on  the 
displacement  even  to  perversio  extrem,a.  .  .  .  The  nisus  depressorius  of 
the  abdomen  awakened  will  assist  the  expulsion." 

Crosse,  who  has  collected  400  cases,  contends  that  the  partial  form 
is  more  frequent  than  is  suspected.  There  are  several  specimens  in 
museums  illustrating  this  partial  inversion. 

Delivery  in  the  upright  posture  has  been  a  not  infrequent  condition. 
Inversion  has  happened  after  delivery  by  ergot  and  the  forceps.  Dr. 
Woodson  relates  a  case  where  inversion  took  place  after  abortion  at 
four  months. 

Inversion  has  been  said  to  have  occurred  several  days  after  delivery. 
An^,  Baudelocque,  and  Dubois  cite  cases.  Some,  at  least,  are  open 
to  the  doubt  that  the  inversion  had  occurred  soon  after  labor,  but  had 
escaped  detection  till  later. 

It  is,  however,  certain  that  the  uterus  may  be  inverted  by  a  process 
of  spontaneous  active  self-inversion.  The  first  distinct  enunciation  of 
the  mode  in  which  this  is  effected,  is  given  by  John  Hunter.  In  the 
Museum  of  the  College  of  Surgeons,  No.  2654  (see  Pathological  Cat- 
alogue), is  a  specimen  of  an  inverted  uterus,  with  a  fibroid  polypus 
detached,  which  had  caused  the  inversion.  The  accident  occurred  in- 
dependently of  pregnancy.  A  polypus  had  been  attached  to  the  fundus. 
A  ligature  had  been  apj^lied  near  the  attachment.  The  tumor  had 
sloughed  off  just  before  the  patient  died.  Hunter  described  the  case 
under  the  title  of  "  Intussusception,"  to  which  he  likens  Inversion. 
"  The  uterus,"  he  says,  "  is  liable  to  inversion  from  two  causes ;  one  is 
immediately  after  labor,  when  it  is  so  large  as  to  admit  of  its  contain- 
ing itself,  and  which  is  commonly  from  an  imprudent  mode  in  disen- 
gaging and  bringing  away  the  placenta,  when  that  substance  has  been 
attached  to  the  fundus  of  the  uterus.  .  .  .  The  second  is  somewhat 
similar,  namely,  the  expulsion  of  an  adventitious  body,  although  of 
another  kind,  and  at  a  very  different  period  in  the  state  of  this  viscus. 
It  begins  to  take  place  when  this  viscus  is  small,  but  becoming 
gradually  large  enough  (by  the  very  disease  that  produces  it)  to  admit 
of  an  inversion  :  so  that  in  the  first  cause,  the  uterus  is  first  large,  so  as 


620  INVERSION    OF    THE     UTEPwUS. 

to  admit  of  an  inversion,  and  by  its  contraction  to  its  natural  state,  it, 
as  it  were,  fixes  it.  This  is  done  immediately,  because  its  cause  is  im- 
mediate, for  this  enlarged  state  of  the  parts  is  of  short  duration ;  but 
the  second  is  gradual,  because  it  is  to  produce  itself,  by  the  very  action 
of  the  uterus  in  expelling  an  unnatural  body  (such  as  a  polypus).  The 
polypus  as  it  grows  will  gradually  fill  the  cavity  of  the  uterus ;  and 
the  uterus  will  be  constantly  endeavoring  to  remove  it.  The  action  of 
the  uterus  will  be  downwards,  and  as  the  body  of  the  uterus  acts  on 
this  substance,  it  will  be  gradually  squeezed  down  towards  the  os  tincse, 
and  the  fundus  will  of  course  be  gradually  drawn  into  its  own  cavity, 
and  as  the  polypus  is  squeezed  down,  so  will  the  fundus  follow.  When 
the  whole  of  the  polypus  has  got  into  the  vagina,  if  it  has  no  length 
of  neck,  then  will  the  fundus  uteri  be  as  low  down  as  the  os  tincse,  the 
upper  half  of  the  uterus  just  filling  the  lower  half;  but  I  conceive  it 
does  not  stop  here ;  I  conceive  the  contained  or  inverted  part  becomes 
an  adventitious  or  extraneous  body  to  the  containing,  and  it  continues 
its  action  to  get  rid  of  the  inverted  part,  similar  to  an  introsusception 
of  an  intestine."  It  is  remarkable  that  in  this  case  an  introsusception 
of  the  small  intestine  coexisted. 

Professor  E.  Martin  relates  a  case  of  complete  inversion  of  the  ute- 
rus in  a  multipara  caused  by  a  fibrous  growth  in  the  fundus.  A  woman, 
aged  forty-six,  was  seized  with  profuse  uterine  hemorrhage,  which 
often  returned.  Two  years  later  a  tumor  was  observed  protruding 
through  the  vulva,  and  causing  retention  of  urine.  The  tumor  was  so 
little  sensitive  that  the  patient  cut  off  a  piece  with  scissors.  It  was  as 
large  as  a  fist.  It  was  found  united  by  a  pedicle  to  the  fundus  of  the 
inverted  uterus,  no  trace  of  os  uteri  being  left.  The  tumor  was  cut 
off  by  an  ecraseur.  Attempt  to  reduce  the  inverted  uterus  was  post- 
poned. A  few  days  afterwards  it  was  found  that  spontaneous  reinver- 
sion  had  taken  place.  The  patient  recovered  (Monatsschr.  f.  Geburtsk., 
1869). 

B.  Langenbeck  (Med.  Centr.-Zeitung,  1860)  exhibited  the  inverted 
uterus  of  a  woman  who  had  never  been  pregnant.  On  the  inverted 
fundus  was  seated  a  fragile,  sarcomatous  heterologous  growth  of  broad 
basis,  the  size  of  a  walnut.  Abarbanell  (Monatsschr.  fiir  Guburtskunde, 
1861)  relates  the  following:  A  woman  had  become  very  anaemic  from 
frequent  hemorrhages.  A  smooth  tumor,  the  size  of  the  fist,  was  first 
felt  protruding  from  the  uterus ;  fourteen  days  later,  under  violent  ex- 
pulsive pains,  with  profuse  hemorrhage,  the  tumor  was  driven  through 
the  external  genitals,  and  the  uterus  was  completely  inverted.  The 
tumor  was  amputated,  whereupon  the  uterus  quickly  replaced  itself 
McClintock  gives  a  case  ("Diseases  of  Women,"  Dublin,  1863).  Dr. 
Emmet  (Amer.  Jour,  of  Obstetrics,  1869)  relates  a  case.  He  first  am- 
putated the  tumor  by  the  wire  ecraseur,  and  subsequently  reduced  the 
inversion  by  the  raanceuvre  described  further  on,  under  the  head  of 
"  Treatment." 

In  University  College  Museum  is  a  remarkable  sjiccimen.  No.  871. 
A  large  mushroom-shaped  tumor  is  attached  to  the  fundus  uteri  by  a 
base  so  broad  that  it  quite  caps  it.  The  uterus  is  laid  open,  showing 
the  round  ligaments  and  tubes  drawn  into  it. 


CAUSES.  621 

This  specimen  is  thus  referred  to  by  Crosse  (part  i,  p.  45) ;  the  case 
is  published  by  D.  D.  Davis,  "Principles  of  Obstetrics/'  (i,  618,  pi. 
21):  "The  patient  was  brought  to  the  Middlesex  Hospital  in  a  dying 
condition ;  the  polypous  tumor  prolapsed  beyond  the  external  labia. 
The  preparation  is  unfavorably  displayed.  Calculating  from  the  ostium 
urethrce,  about  one  inch  of  the  vagina  remains  uninverted,  so  that  the 
angle  of  its  reflection,  where  the  circular  cul-de-sac  terminates,  is  situ- 
ated at  the  depth  of  an  inch,  from  which  the  inverted  vagina  extends  down- 
wards two  inches,  forming  a  tube,  which  terminates  in  the  uterus,  at  which 
termination  there  is  a  distinct  thickening  or  circular  prominence,  an- 
swering to  the  cervix  uteri,  completely  inverted.  The  cut  surface  of 
the  inverted  uterus  is  nearly  an  inch  in  thickness,  and  the  peritoneal 
pouch  formed  by  it  is  very  small,  and  its  whole  extent  is  laid  open. 
There  is  no  observable  alteration  in  the  bladder  from  its  normal  posi- 
tion, the  superior  fundus  rising  prominently  towards  the  abdomen;  and 
in  the  posterior  view  the  ovaria  are  of  large  size,  and  lie  close  to  each 
other  at  the  margin  of  the  peritoneal  pouch,  tucked  in  behind  the  blad- 
der. The  peritoneal  pouch,  though  narrow,  must  be  about  four  inches 
in  length,  two  answering  to  the  inverted  vagina,  and  the  rest  to  the 
uterus  totally  inverted.  The  left  corpus  iimbriatum  is  adherent,  the 
right  loose  and  floating." 

In  St.  Bartholomew's  Museum  is  a  specimen  (No.  32.12)  illustrating 
this  point.  "  The  uterus  contains  a  large  fibrous  tumor  which  has  grown 
from  its  fundus,  and  projects  into  the  vagina.  The  fundus  of  the  uterus 
is  partially  inverted,  being  drawn  down  by  the  weight  of  the  tumor.  Its 
inner  layers  also,  enveloping  the  tumor,  are  elongated,  so  as  to  form  a 
pedicle  or  neck  by  which  the  tumor  is  attached  like  a  polypus.  Similar 
tumors  of  smaller  size  have  formed."  In  St.  Bartholomew's  Reports, 
1872,  another  history  is  related  of  inversion  caused  by  a  i>olypus.  The 
uterus  was  restored  to  its  position. 

The  symptoms  of  recent  inversion  are  chiefly  those  of  shock,  indicat- 
ing sudden  severe  injury.  They  vary  with  the  degree  and  progress  of 
the  inversion.  Thus,  the  first  degree,  or  simple  depression,  may  be  un- 
attended by  pain,  and  indicated  solely  by  hemorrhage  and  a  corre- 
sponding depression  of  the  vital  powers.  The  hemorrhage  comes 
from  the  relaxed  introcedent  part.  The  depression  at  the  fundus  may 
be  felt  through  the  abdominal  walls  as  a  cup-like  hollow.  As  the 
descent  proceeds,  and  becomes  introversion,  urgent  symptoms  arise, 
according  to  the  degree  of  compression  exercised  by  the  uninverted 
portion  upon  the  inverted  portion.  A  sense  of  fulness,  weight,  as  of 
something  to  be  expelled,  is  felt.  Expulsive  eiforts,  both  uterine  and 
abdominal,  sometimes  very  violent,  follow.  Hemorrhage  is  not  con- 
stant. It  seems  that  when  the  inverted  portion  is  firmly  compressed, 
the  hemorrhage  is  arrested,  and  that  bleeding  is  a  mark  of  inertia. 
When  the  inversion  is  complete,  the  uterus  is  felt  in  the  vagina,  or 
may  even  be  seen  outside  the  vulva.  Then  pain  and  collapse  are  aggra- 
vated. Clammy  sweats,  cold  extremities,  vomiting,  alarming  distress, 
restlessness,  extinction  of  the  pulse  occur.  During  the  expulsion  the 
woman  has  often  exclaimed  that  her  intestines  were  passing  from  her. 
A  tumor  appears  in  the  vagina,  or  externally,  generally  covered   by 


622  INVERSION    OF    THE    UTERUS. 

the  placenta.  The  cord  is  traced  up  to  the  insertion,  and  the  placenta, 
of  convex  form,  is  spread  over  the  tumor. 

The  shock,  either  with  or  without  hemorrhage,  is  sometimes  so  great 
as  to  quiclvly  extinguish  life.  Cases  are  known  where  the  shock  at- 
tending simple  depression  has  been  fatal.  Where  the  case  is  not  fatal, 
and  the  uterus  is  not  reduced,  the  symptoms  of  chronic  inversion  suc- 
ceed. First,  the  tumor  by  its  bulk  causes  distress  of  the  bladder  and 
rectum.  Then  it  is  probably  forced  externally.  Chronic  inflamma- 
tion, thickening  and  induration  of  the  parts  ensue;  the  surface  may  be- 
come dry  from  exposure,  or  ulcerated  and  bleeding  from  chafing.  It 
may  be  difficult  or  impossible  to  reduce  it  within  the  vagina.  If  the 
tumor  remain  within  the  vagina,  it  may  still  be  a  source  of  chronic 
irritation  to  the  vagina,  and  may  itself  be  the  seat  of  chronic  inflamma- 
tion. Congestion,  abrasion  of  surface,  ulcerations,  give  rise  to  pro- 
fuse muco-purulent  leucorrhoea,  frequently  to  hemorrhage.  Irritative 
fever,  emaciation,  pain,  discharges,  break  down  the  constitution,  and 
after  some  mouths,  or  even  years,  the  patient  may  sink  from  exhaus- 
tion. As  Windsor  remarked,  an  epoch  of  special  danger  is  that  of 
weaning  and  the  resumption  of  menstruation.  The  discharges  of  blood 
then  become  more  frequent  and  profuse.  When  the  climacteric  age 
has  been  reached,  the  uterus  undergoing  natural  atrophy,  severe  symp- 
toms may  subside,  toleration  ensuing. 

In  the  recent  state  retention  of  urine  is  not  uncommon,  owing  to  the 
distortion  aud  compression  of  the  neck  of  the  bladder  and  urethra. 
The  retention  has  been  relieved  when  the  uterus  was  restored. 

Cases  have  been  known  of  the  inverted  uterus  sloughing  off: 
Saxtorph  (in  Actis  Soc.  Med.  Hav.) ;  Deborieir  (Hichter's  Chir.  Bibl.) ; 
Radford  (Dublin  Journ.  of  Med.,  1835).  In  other  cases  the  strangula- 
tion caused  by  the  cervix  has  ended  fatally  before  there  was  time  for 
sloughing  (Velpeau).  More  marvellous  still,  cases  have  occurred  in 
which  the  recently  inverted  uterus  has  been  torn  away  by  the  attendant, 
the  patient  recovering  (Dr.  J.  C.  Cooke).  J.  L.  Casper  says  (Hand- 
book of  Forensic  Medicine,  New  Sydenham  Soc.  Translation,  vol  iii) 
laceration  of  the  pelvic  ligaments  may  attend  spontaneous  inversion  of 
the  uterus. 

E.  Clemensen  relates'  a  case  of  complete  inversion,  in  which  the 
uterus  separated  by  gangrene.  A  woman  at  fifty  had  borne  two  chil- 
dren, the  last  thirteen  years  ago.  Some  eight  years  ago  she  observed 
that  the  uterus  prolapsed  (it  was  probably  inverted).  A  profuse  hemor- 
rhage took  place.  The  uterus  was  then  found  completely  inverted 
between  the  thighs,  the  size  of  two  fists.  In  several  spots  lacerations 
were  observed  extending  into  the  muscular  tissue.  Some  days  later 
the  uterus  seemed  diminished  in  size;  irritative  fever  set  in;  gangrene 
showed  itself  in  the  left  side  of  the  uterus.  The  uterus  contracted  more 
and  more.  At  last  only  the  orifice  remained  as  a  scar.  The  woman 
recovered.  Clemensen  attributes  the  origin  of  the  inversion  to  the  altered 
texture  of  the  organ,  resulting  from  fatty  regression  after  labor. 

In  recent  inversion  death  has  ensued  from  strangulation  of  intestine 

1  Hospital  Tidende,  1865. 


CONSEQUENCES.  623 

in  the  uterus.  Gerard  de  Beauvais  relates  a  case  (Acad.  Medecine, 
1843).  But  such  a  termination  can  hardly  occur  when  the  inversion  has 
become  chronic.  It  is  a  remarkable  circumstance  that  notwithstanding 
the  extreme  difficulty  experienced  in  reducing  an  inverted  uterus,  it 
very  rarely  happens  that  the  constriction  of  the  os  is  sufficient  to  close 
the  inverted  cavity,  or  that  adhesion  exists.  Commonly  the  finger  is 
readily  admitted,  and  even  through  the  abdominal  wall  a  passage  into 
the  cavity  may  be  felt. 

Sometimes,  the  uterus  being  irreducible,  death  ensues  from  hemor- 
rhage, as  in  a  case  described  in  St.  Bartholomew's  Catalogue  (specimen 
No.  32.56),  and  reported  by  Dr.  West  (Pathological  Proceedings,  vol. 
iii).  "  Uterus  entirely  inverted,  with  the  exception  of  the  os,  which, 
however,  does  not  cause  any  constriction,  the  finger  passing  easily 
between  it  and  the  uterine  wall.  The  openings  of  Fallopian  tubes  not 
discovered.  The  peritoneum  at  the  jDoint  of  inversion  is  thickened  and 
uneven,  the  insertions  of  the  uterine  appendages  are  drawn  into  the 
cul-de-sac  of  inverted  uterus.  This  inversion  was  irreducible,  and  the 
displacement  of  the  uterus  caused  death  in  consequence  of  frequently 
recurring  hemorrhage  twenty-nine  months  after  its  occurrence." 

A  remarkable  termination  is  illustrated  in  the  following  case,  of 
which  the  specimen  is  preserved  in  the  London  Hospital  (No.  Ea  57) : 
"  Uterus  perforated  at  its  fundus  by  disease.  Its  mucous  membrane 
appears  to  have  been  everywhere  destroyed,  and  at  its  fundus  is  an 
aperture  the  size  of  a  shilling."  Dr.  Ramsbotham  thus  refers  to  it: 
"  Ulceration  having  commenced  in  the  whole  lining  membrane  of  the 
uterus  has  almost  destroyed  the  uterine  texture,  and  has  formed  an 
opening  into  the  peritoneal  cavity.  The  uterus  is  turned  inside  out. 
Epithelial  carcinoma  of  the  internal  uterine  membrane.  I  have  seen 
only  one  other  such  case." 

Crosse  says,  "  There  is  not  a  shadow  of  evidence  of  total  inversion  in 
the  strict  sense  replacing  itself  spontaneously."  A  few  cases,  as  those 
related  by  Boyer  (Maladies  Chirurgicales)  and  Baudelocque  (Daillez, 
These)  are  examples  of  reduction  following  external  force  in  the  form 
of  a  blow  or  succussion.  Dr.  Meigs,  nevertheless,  relates  several  cases. 
Of  such  cases  Dr.  West  remarks  that  "  it  is  easier  to  conceive  that  an 
experienced  man  should  commit  an  error  of  diagnosis,  than  to  under- 
stand how  any  effi3rts  of  nature  could  cure  a  chronic  inversion  of  the 
womb."  The  error  may  be  one  of  the  two  following — either  the  tumor 
was  a  polypus,  which  has  disappeared  by  being  spontaneously  cast 
off,  or  it  was  a  true  inverted  uterus,  which  has  been  separated  by 
sloughing,  and  cast  off  in  like  manner. 

In  some  instances  the  subject  of  inversion  has  evinced  more  or  less 
perfect  toleration  of  her  infirmity.  This  was  the  result  in  a  case  reported 
by  Guyon  (Journ.  de  Chir.  et  de  Med.  Prat.,  1861),  in  which  inversion 
had  existed  twenty  years  without  alteration  of  health ;  in  one  by  Dr. 
Comstock  (Boston  Med.  and  Surg.  Journ.,  vol.  viii),  the  patient  fol- 
lowed her  occupation  as  a  dairymaid  ;  in  one  by  Dewees  (Midwifery),. 
she  was  enjoying  good  health  ten  years  after  the  accident ;  in  one  by 
Ramsbotham,  the  patient  regained  flesh,  her  health  became  good ;  in 
one  by  Lisfranc  (Clin.  Chir.,  1843),  he  examined  the  body  of  an  old 


624  I]S'VEIlSION    OF    THE    UTERUS. 

woman  at  the  Salpetriere,  the  uterus  was  completely  inverted,  it  had 
not  been  suspected  daring  life;  in  one  by  Dr.  C.  H.  Lee  (American 
Journ,  of  Med.  Sc,  1860),  inversion  remained  undetected  for  twenty- 
five  years,  ablation  was  given  up,  the  patient  was  so  well ;  in  other 
cases  referred  to  by  Gregory  Forbes,^  in  one  reported  by  Dr.  Woodman 
(Obstet.  Trans.,  vol.  ix),  brought  to  the  London  Hospital  whilst  I  was 
obstetric  physician  there,  and  in  Dr.  Mackenzie's  case  (see  Fig.  135), 
toleration  was  established. 

When  reduction  has  been  effected,  the  uterus  may  recover  its  func- 
tion, and  pregnancy  ensue.  There  is  also  a  probability,  not  indeed 
high,  but  suggesting  caution,  that  inversion  will  again  take  place  dur- 
ino-  labor.  For  a  long  time  after  replacement  the  cavity  of  the  uterus 
probably  remains  shorter  than  normal.  The  thickened  walls  take  time 
to  resume  their  natural  condition.  I  state  this  from  the  observation  of 
a  ease  reduced  by  myself.  This  depends  no  doubt  in  some  instances 
upon  the  reduction  being  imperfect,  the  fundus  remaining  in  the  state 
of  depression,  or  squatting. 

The  prognosis  must  always  be  serious.  Weber  truly  calls  inversion 
"malum  ingeiis  periculique  plenum."  Crosse,  who  has  shown  the  great- 
est industry  in  the  collection  of  cases,  says  that  above  one-third  of  all 
the  cases,  under  whatever  circumstances,  or  in  vvhatever  degree  they 
occur,  prove  fatal  either  very  soon,  or  within  one  month.  He  analyzed 
109  fatal  cases.  Seventy-two  proved  fatal  within  a  few  hours,  most  of 
them  within  half  an  hour ;  eight  cases  proved  fatal  in  from  one  to  seven 
days;  and  six  in  from  one  to  four  weeks.  If  the  patient  survive  a 
mouth,  the  case  is  chronic,  and  the  immediate  danger  is  small.  But 
the  danger  recommences  at  eight  or  nine  months,  when  the  menstrual 
function  is  resumed.  Many  of  these  will  die  within  two  years.  If  the 
inversion  take  place  suddenly  and  completely,  the  uterus  remaining 
flaccid,  the  danger  is  extreme ;  if  it  take  place  slowly,  that  is,  under 
spontaneous  uterine  action,  the  danger  is  less. 

As  to  the  prospect  of  reduction,  a  much  more  favorable  expectation 
than  was  lately  held  is  justified  by  the  improved  methods  of  treatment; 
and  reduction  will  diminish  the  mortality.  Denman  thought  that  if 
two  hours  had  elapsed,  reduction  could  not  be  effected.  But  more 
recent  experience  has  abundantly  proved  that  both  in  the  recent  and 
chronic  cases  reduction  can  in  the  great  majority  of  instances  be  accom- 
plished. If  the  patient  survive  the  first  dangers  of  shock  and  hemor- 
rhage the  prospect  of  recovery  under  surgical  treatment  is  good. 

The  diagnosis  is  especially  important;  it  is  not  always  easy;  and 
the  most  deplorable  consequences  have  followed  from  error.  M.  A. 
Petit  had  a  patient  in  the  hospital  at  Lyons.  Six  surgeons  decided 
that  it  was  polypus,  and  a  ligature  was  applied.  A  shriek  caused  sus- 
picion of  inversion  ;  the  ligature  was  removed  ;  but  the  woman  died  at 
the  end  of  five  days.  On  examination  inversion  was  found.  Dr.William 
Hunter  tied  what  he  thought  was  a  polypus  in  a  young  woman  who 
said  she  had  never  been  pregnant.  She  died ;  the  uterus  was  found 
inverted. 


1  Medico-Chirurgical  Transactions,  vol.  xxxv. 


DIAGNOSIS.  625 

Dubois  (Dictionnaire  de  Med.,  1846)  says  he  knew  of  two  cases  of 
inversion  mistaken  for  polypus  by  two  of  the  most  skilful  surgeons  in 
Paris.  In  one  case  a  ligature  was  put  on;  the  patient  died  in  thirty- 
six  hours. 

In  the  presence  of  the  recent  accident  the  most  frequent  mistakes 
have  been  to  suppose  the  mass  is  a  second  placenta,  or  the  head  of  a 
second  foetus.  The  forceps  has  been  applied  to  the  inverted  uterus  to 
drag  it  away. 

The  diagnosis  is  especially  difficult  when  inversion  is  complicated 
with  polypus.  The  polypus  may  be  detected,  but  not  the  inversion, 
and  a  ligature  applied  to  the  polypus  may  include  a  portion  of  the 
uterus.  Gooch  relates  ("  Diseases  of  Women  ")  the  following  case :  Dr. 
Denman  passed  a  ligature  round  a  polypus  of  the  fundus ;  as  soon  as 
he  tightened  it,  he  produced  pain  and  vomiting.  As  soon  as  the  liga- 
ture was  slackened,  these  symptoms  ceased ;  but  whenever  he  attempted 
to  tighten  it, the  pain  and  vomiting  returned;  the  ligature  was  left  on, 
but  loose ;  the  patient  died  about  six  weeks  afterwards,  and  on  opening 
the  body  it  was  discovered  that  the  uterus  was  inverted,  and  that  the 
ligature  had  included  the  inverted  portion. 

The  following  case  occurred  to  Dr.  Gooch  at  Bartholomew's  in  1828: 
The  patient  had  been  delivered  by  forceps  six  months  before.  When 
standing,  a  large  tumor  protruded  externally,  but  could  easily  be  re- 
placed. The  OS  uteri  could  not  be  felt.  The  ligature  was  applied 
round  what  was  supposed  to  be  the  stalk  of  the  tumor :  it  occasioned 
little  pain  when  first  applied,  but  towards  evening  pain  became  so  severe 
as  to  resemble  labor.  She  died  on  the  fifteenth  day  after  the  operation. 
The  uterus  was  of  natural  size  and  structure.  The  tumor  grew  from 
the  orifice  of  the  uterus  all  round,  so  as  to  be  continuous  with  the  cer- 
vix, and  to  make  it  impossible  to  say  where  the  neck  of  the  uterus 
ended  or  the  stalk  of  the  tumor  began.  The  ligature  had  included  the 
projecting  neck  of  the  uterus.  The  posterior  part  had  occasioned  ulcera- 
tion into  the  cavity  of  the  peritoneum.  There  was  no  inflammation  of 
the  peritoneum. 

The  diagnosis  has  to  be  made  under  the  two  different  circumstances 
of  recent  occurrence  and  chronicity.  In  the  first  case,  the  history  fur- 
nishes useful  indications.  The  sudden  sense  of  injury  and  shock,  fol- 
lowing labor,  suggests  immediate  exploration.  Negative  and  positive 
signs  occur  in  pointing  to  a  conclusion.  In  the  first  place  the  uterus 
is  not  felt,  as  it  ought  to  be,  a  firm,  round  ball  behind  the  pubes.  On 
pressing  the  hand  firmly  into  the  pelvic  cavity  from  above  downwards, 
behind  the  symphysis,  a  vacuum  is  felt.  Keeping  the  hand  in  this 
situation,  the  fingers  of  the  other  hand  are  passed  into  the  vagina,  and 
there  a  mass  rounded,  soft,  or  firm  is  felt.  The  relations  and  position 
of  this  mass  are  clearly  defined  between  the  two  hands.  If  the  placenta 
is  attached,  the  uterus  is  obscured  by  it.  But  bared,  the  diagnosis  will 
be  cleared  up,  if  the  finger  is  carried  all  round  the  mass  up  to  its  inser- 
tion. On  pressing  the  mass  upwards  as  in  attempt  to  replace  it,  the 
fingers  exploring  through  the  abdominal  wall  will  sink  into  a  pit  formed 
by  the  disappearance  of  the  uterus  through  its  os.  Then  the  finger  in 
the  vagina  exploring  the  root  or  insertion  of  the  tumor  comes  to  a  cir- 

40 


626  INVERSION    OF    THE    UTERUS. 

cular  farrow  at  the  fundus  of  the  vagina,  and  a  prominent  ring,  which 
is  the  OS  uteri.  If  the  inversion  be  not  complete,  the  finger,  or  more 
easily  the  uterine  sound,  will  pass  a  little  way  between  the  ring  formed 
by  the  os  and  the  pedicle  of  the  tumor.  If  the  inversion  is  complete, 
only  the  furrow  will  be  felt.  If  the  inversion  has  been  followed  by 
prolapse  of  the  mass  beyond  the  vulva  the  exploration  is  easier,  as  the 
tumor  may  then  be  felt  continuous  by  its  origin  with  the  inverted 
vagina.  It  may  also  be  seen.  Its  aspect  is  that  of  a  florid  tumor  with 
a  very  vascular  velvety  surface,  easily  bleeding  on  the  slightest  touch, 
or  if  the  presenting  part  be  that  to  which  the  placenta  had  grown,  it  is 
uneven,  of  a  dark  hue,  with  placental  shreds  or  coagula  attached  to  it. 
The  tumor  is  painful  to  the  touch.  Any  attempt  to  drag  upon  it  causes 
a  sensation  described  by  the  patient  as  if  her  inside  were  being  pulled 
out.  Pain  is  also  felt  down  the  legs.  Vomiting  is  likely  to  occur.  In 
size  the  tumor  may  equal  a  child's  head,  or  it  may  be  no  larger  than  a 
fist.  A  crucial  test  is  the  alternation  of  the  mass  from  contraction  to 
dilatation.  This  vital  act  inducing  characteristic  changes  of  size  and 
consistence  pertains  to  the  uterus  alone. 

The  diagnosis  from  polypus  is  not  always  easy.  A  polypus  may 
complicate  pregnancy.  Pregnancy  usually  causes  an  intra-uterine 
polypus  to  grow  at  an  accelerated  ratio.  After  the  birth  of  the  child, 
the  polypus  will  be  extruded,  perhaps  dragging  the  fundus  uteri  a 
little  with  it,  thus  simulating,  if  not  producing,  a  minor  degree  of  in- 
version. To  distinguish  this  from  inversion  it  must  be  remembered 
that  polypus  thus  appearing  after  labor  is  actually  even  more  rare  than 
inversion.  The  probability,  therefore,  of  inversion  ought  to  operate 
with  at  least  equal  force  upon  the  mind  of  the  surgeon.  The  chief 
points  of  distinction  are:  that  a  polypus  is  not  sensitive;  it  does  not 
change  its  form  or  size ;  it  does  not  contract  or  relax.  Its  expulsion  does 
not  produce  severe  shock.  In  form  and  size  polypus  may  resemble  in- 
version, but  it  differs  in  relation  to  other  parts.  It  is  quite  possible  that 
the  placenta  may  have  been  partially  attached  to  the  surface  of  the  poly- 
pus; it  will  then  exhibit  placental  shreds  and  clots  like  the  uterus.  The 
finger  and  sound  must  be  relied  upon  to  make  the  case  manifest.  The 
hand  outside  will  discover  the  uterus  in  situ  behind  the  pubes.  The  finger 
in  the  vagina  Avill  travel  round  the  polypus,  between  it  and  the  ring  of 
the  OS  uteri  which  embraces  it.  If  the  attachment  of  the  tumor  is  to  the 
cervix,  the  pedicle  will  be  felt  on  one  side  of  the  circumference,  whilst  in 
the  other  parts  the  finger  or  sound  will  pass  several  inches  beyond  into 
the  cavity  of  the  uterus.  If  the  attachment  is  at  the  fundus,  then  the 
sound  will  pass  all  round. 

A  case  lately  occurred  in  London  in  which  the  recently  inverted 
uterus  was  mistaken  for  a  polypus.  Extreme  exhaustion  from  hemor- 
rhage ensued,  for  which  transfusion  was  successfully  employed  by  Dr. 
Aveling,  who  also  detecting  the  true  cause  of  the  hemorrhage,  restored 
the  uterus  on  the  third  day. 

The  difficulty  of  distinguishing  inversion  in  the  chronic  state  from 
polypus  is  greater.  Velpeau  having  in  error  tied  an  inverted  uterus, 
said,  "  I  know  too  well  that  there  are  cases  in  which  doubt  is  the  only 
rational  opinion."    Soon  after  the  accident  the  uterus  diminishes  greatly 


DIAGNOSIS.  627 

in  bulk,  becomes  harder,  perhaps  less  sensitive,  and,  in  these  features, 
more  nearly  resembles  polypus.  But  setting  the  history — always  a 
fallacious  diagnostic  element — apart,  the  means  of  discrimination  are 
satisfactory.  The  speciilum  may  reveal  the  oozing  of  the  menstrual 
fluid.     In  other  respects  its  use  is  doubtful. 

The  sound  (Simpson,  Edin.  Med.  Jour.,  1843)  is  of  more  value.  "If 
it  passes  two  inches  and  a  half  or  more  beyond  the  edge  of  the  cervix, 
the  disease  is  not  inversion  of  the  fundus;  if  it  cannot  pass  at  any  point 
around  the  stem  of  the  tumor  to  a  greater  extent  than  about  one  inch, 
the  uterine  cavity  may  be  considered  as  shortened  by  inversion."  The 
inverted  uterus  is  flattened  anteriorly  and  posteriorly ;  its  largest  point 
is  lowest;  it  diminishes  very  gradually,  presenting  a  comparatively 
large  neck  at  its  highest  part,  where  it  is  encircled  by  the  inverted  cer- 
vix, if  the  inversion  is  not  complete,  and  by  a  thickened  ring  or  ridge 
if  complete.  The  size  of  the  inverted  uterus  is  scarcely  larger,  and  is 
often  smaller,  than  in  the  natural  state.  Herbiniaux  placed  so  much 
stress  upon  this  as  to  affirm  "  that  if  the  tumor  be  so  large  as  to  distend 
the  vagina  and  prevent  your  getting  at  the  os  uteri,  it  may  be  boldly 
pronounced  polypus,  and  not  a  partial  inversion,  which  is  always  of 
small  size,  and  tills  the  vagina." 

The  form  of  the  tumor  has  been  thought  to  offer  distinctive  characters. 
S.  Cooper  described  the  inverted  uterus  as  forming  a  mass  wider  or  as 
wide  above  at  its  origin  as  at  its  most  dependent  part,  whereas  in  poly- 
pus the  neck  is  narrower.  This  is  often  true,  but  not  constantly  so; 
and  it  would  not  be  safe  to  rely  upon  a  variable  sign.  J.  G.  Forbes 
describes  a  case  of  complete  inversion  of  eighteen  months'  standing,  in 
which  the  tumor  close  to  the  os  was  four  inches  and  a  quarter  in  cir- 
cumference; this  was  the  widest  part.  This  seems  to  be  more  espe- 
cially the  character  of  incomplete  inversion.  In  many  cases  of  complete 
inversion  the  upper  part  is  narrowed  so  as  not  to  be  distinguished  in 
this  respect  from  many  polypi.  This  was  the  condition  in  two  cases 
observed  by  myself. 

A  sign  insisted  upon  by  Crosse  is  the  feeling  the  stretched  round 
ligaments  within  the  tumor  (inverted  uterus),  and  pain  being  produced 
in  the  groins  on  lowering  the  tumor  a  little  so  as  to  render  the  tension 
greater.  To  this  I  would  add  that  by  drawing  the  tumor  well  down 
by  a  vulsellum  or  a  noose  (see  Fig.  137,  p.  636),  the  insertion  of  the 
root  in  the  vaginal  roof  being  put  on  the  stretch,  the  continuity  of  the 
two  parts  is  made  manifest. 

Malgaigne  advises  the  following  method :  Introduce  a  male  catheter 
into  the  bladder,  direct  its  end  downwards  and  backwards,  so  that, 
carrying  the  coats  of  the  bladder  before  it,  it  may  enter  the  peritoneal 
cul-de-sac  formed  by  the  inversion,  and  be  felt  by  the  finger  in  the 
vagina  through  the  coats  of  the  inverted  organ.  Another  method  is 
this :  The  catheter  in  the  bladder,  direct  the  end  backwards  so  as  to 
bring  it  to  project  in  the  rectum,  where  a  finger  will  feel  it  with  only 
the  coats  of  the  rectum  and  bladder  intervening;  but  if  the  firm  resist- 
ing uterus  be  there,  the  end  of  the  catheter  will  not  be  felt.  Digital 
examination  by  the  rectum  will  also  enable  the  surgeon  to  explore  the 
tumor  in  the  vagina  more  fully.     Often  the  end  of  the  finger  will  get 


628  INVERSION    OF    THE    UTERUS. 

above  the  tumor,  thus  completely  exploring  it.  If  the  uterus  be  iu  its 
place,  it  may  thus  be  felt  between  the  finger  in  the  rectum  and  the 
finger  of  the  other  hand  pressed  down  behind  the  pubes.  If  the  uterus 
be  inverted,  then  the  vacuity  above  the  tumor  felt  in  the  vagina  will 
indicate  that  this  tumor  is  the  uterus.  This  mode  of  exploration 
should  never  be  omitted.  Dubois  takes  occasion  to  say  that  the  mis- 
takes he  refers  to,  in  which  death  occurred  from  ligaturing  an  inverted 
uterus,  would  not  have  been  made  if  exploration  by  catheter  in  bladder 
and  finger  in  rectum  had  been  resorted  to.  Where  doubt  exists  there 
is  still  another  mode  of  exploration  which  gives  absolute  evidence. 
Under  chloroform  the  hand  may  be  passed  into  the  rectum,  so  that  the 
fingers  may  feel  above  the  tumor  and  completely  command  its  whole 
contour.  The  operation  is  not  very  difficult,  and  if  carefully  performed 
no  injury  will  result. 

An  intra-uterine  polypus  sessile  on  a  broad  basis  may  simulate  par- 
tial inversion.  The  diagnosis  will  be  established  by  the  hand  outside 
feeling  the  unimpaired  rotundity  of  the  uterine  fundus  in  the  first  case ; 
and  the  cup-shaped  depression  on  its  sphere  in  the  second  case.  The 
sensitivenesss  of  the  inverted  uterus  furnishes  indications.  Thus 
Gueniot  (Arch.  Gen.  de  Medecine,  1868)  recommends  acupuncture  of 
the  tumor  to  test  this  property.  But  it  must  be  confessed — at  least,  I 
make  this  admission  on  my  own  behalf — that  the  sensitiveness  of  the 
inverted  uterus  has  been  more  distinctly  revealed  by  applying  a  liga- 
ture or  wire  around  its  neck  with  a  view  to  removal  for  a  polypus. 
Regarding  this  fact,  and  the  associated  fact,  that  a  polypus  is  not  sensi- 
tive, I  have  insisted  upon  the  rule  that  patients  should  never  be  sub- 
mitted to  anaesthesia  for  the  removal  of  a  polypus.  Pain  may  give  the 
last  warning,  and  save  the  patient  at  the  last  moment. 

The  diagnosis  from  prolapse  of  the  uterus  and  vagina  ought  not  to 
be  doubtful.  The  presence  of  the  os  uteri  at  the  lowest  point  of  the 
tumor,  admitting  the  sound  for  a  distance  of  two  and  a  half  inches  or 
more,  at  once  decides  the  existence  of  prolapsus. 

The  difficulty  of  diagnosis  has  been  felt  even  in  the  presence  of  the 
parts  put  up  in  spirit.  Thus  Crosse,  by  further  dissection,  proved  that 
a  specimen,  which  for  years  had  passed  for  one  of  inversion  in  the  Glas- 
gow museum,  was  in  reality  one  of  polypus  growing  from  and  perfectly 
occluding  the  os  uteri.  He  pleads  with  pardonable  urgency  that  the 
mode  of  putting  up  these  specimens  is  bad ;  and  that  the  tumor  ought 
to  be  slit  open  by  a  longitudinal  cut  so  as  to  expose  the  cavity  and  its 
contents. 

I  possess  a  wax-model  taken  from  a  patient  who  came  under  my  care 
in  the  London  Hospital.  There  was  a  procident  mass  outside  the  vulva 
which  was  for  some  time  taken  to  be  a  fibroid  tumor  attached  to  the 
fundus  of  the  inverted  uterus.  It  was  only  after  prolonged  examina- 
tion that  a  small  opening,  seated  in  the  angle  of  junction  of  the  tumor, 
was  discovered  by  means  of  the  sound  to  be  the  os  uteri.  The  tumor 
had  grown  by  a  broad  basis  to  the  cervix,  and  had  caused  not  inversion 
but  ])rolapsus.     The  model  is  figured  in  the  Obstetrical  Trans.,  vol.  iii. 

What  has  been  said  will  indicate  some  of  the  principles  of  treatment. 
Attempts  to  reduce  should  be  made  as  early  as  possible ;  but  success 


TREATMENT.  629 

should  never  be  despaired  of.  In  the  recent  accident  we  may  or  may 
not  liave  the  attaclied  placenta  complicatino;  the  case.  Should  we  first 
detach  the  placenta  ?  If  we  do,  we  lose  a  little  time.  If  we  do  not, 
there  is  the  greater  bulk  to  pass  back  through  the  os  uteri.  I  believe 
it  is  the  better  practice  to  get  rid  of  the  complication  first.  To  effect 
it,  look  for  the  margin  of  the  placenta,  insinuate  one  or  two  fingers 
between  it  and  the  globe  of  the  uterus ;  supporting  this  organ  by  the 
other  hand,  continue  to  peel  off  the  placenta  by  sweeping  the  fingers 
along.  When  it  is  wholly  detached,  proceed  to  reduction.  The  mode 
of  manipulation  must  vary  according  to  circumstances.  If  the  uterus 
is  large,  flabby,  and  the  cervix  dilated,  it  may  be  quickly  replaced  by 
depressing  the  fundus  with  the  fingers  gathered  into  a  cone,  and  carry- 
ing the  hand  onwards  through  the  os.  Lazzati  recommends  to  apply 
the  closed  fist  to  the  fundus.  This  is  better  than  the  fingers  which,  as 
he  truly  says,  might  perforate  the  uterine  wall.  In  executing  this,  two 
things  must  on  no  account  be  omitted  :  one  is  to  support  the  uterus  by 
the  other  hand  pressing  firmly  down  upon  it  from  above  the  symphysis 
pubis  externally,  lest  we  lacerate  the  vagina;  the  other  is  to  observe 
the  course  of  the  pelvic  axes,  and  the  form  of  the  pelvic  brim.  Pres- 
sure will  first  be  made  a  little  backwards  towards  the  hollow  of  the 
sacrum  ;  then  the  direction  must  be  forwards  to  the  brim,  and  at  the 
same  time  to  one  side  so  as  to  avoid  the  sacral  promontory,  as  in 
attempts  to  reduce  a  retroverted  gravid  uterus,  failure  has  often  ensued 
from  not  understanding  this  latter  point.  It  was  first,  I  believe, 
pointed  out  by  Dr.  Skinner,  of  Liverpool,  I  can  testify  to  the  value- 
of  the  rule  from  personal  experience.  By  attention  to  it  mainly,  I 
was  enabled  to  reduce  a  uterus  in  fifteen  minutes  which  had  been  in- 
verted for  ten  days,  defying  repeated  efforts  of  other  practitioners. 
The  patient  made  a  good  recovery.  When  reduction  has  been  com- 
pleted, the  hand  following  the  receding  fundus  will  occupy  the  cavity 
of  the  uterus,  and  the  organ  will  be  grasped  between  the  hand 
inside  and  the  hand  supporting  outside.  The  opportunity  should  be 
taken  to  induce  contraction,  by  pressure  externally,  and  by  excitation 
internally.  But  I  would  not  withdraw  the  hand  from  the  cavity,  lest 
re-inversion  take  place,  until  I  had  taken  the  following  further  security. 
Pass  up  along  the  palm  of  the  hand  a  uterine  tube  connected  with  a 
Higginson's  injecting-syringe ;  throw  up  by  means  of  this  six  or  eight 
ounces  of  a  mixture  composed  of  equal  parts  of  the  strong  solution  of 
perchloride  of  iron  (Brit.  Pharm.,  1867)  and  water,  so  as  to  bathe  the 
whole  inner  surface  of  the  uterus.  The  effects  of  this  are  to  instantly 
constringe  the  mouths  of  the  vessels,  to  stop  bleeding,  to  excite  uterine 
contraction,  and  to  corrugate  the  tissues.  When  this  state  is  induced 
there  is  safety.  Or  the  stypic  may  be  applied  by  swabbing  by  means 
of  a  pledget  of  cotton  or  sponge  carried  on  a  probang. 

If  uterine  action  be  present,  especially  if  the  cervix  and  os  are  con- 
stringing  the  inverted  part,  the  difficulty  is  greater,  and  it  is  no  longer 
judicious  to  commence  by  pushing  in  the  fundus.  As  Dr.  McClintock 
("  Diseases  of  Women,"  1863)  has  well  shown,  to  do  this  is  to  double 
the  inflexion  of  the  uterine  walls,  and  thus  to  double  the  thickness  of 
the  mass  that  has  to  pass  through  the  os.     He  advocates  the  method 


630  iNVERSioisr  of  the  uterus. 

practiced  by  Montgomery,  which  consists  in  regarding  the  inversion  as 
a  hernia,  and  in  replacing  that  part  first  which  came  down  last.  The 
tumor  must  be  grasped  in  its  circumference  near  the  constricting  os ; 
firmly  compressing  it  towards  the  centre ;  and  at  the  same  time  push- 
ing it  upwards,  forwards,  and  to  one  side.  The  pressure  must  be 
steadily  kept  up,  as  it  is  sustained  pressure  that  wears  out  the  resist- 
ance of  the  OS.  After  a  time  the  os  is  felt  to  relax,  the  part  nearest  is 
pushed  through,  and  then  generally  suddenly  the  body  and  fundus 
spring  through.  Two  things  facilitate  this  operation  :  chloroform  and 
a  semi-prone  position  of  the  patient. 

In  recent  inversion  reduction  has  been  effected  by  the  aid  of  cold 
irrigation.  Dr.  Ch.  Martin,  of  Orleans,  relates  (Gaz.  des  Hop.,  1853) 
a  case  in  which  success  attended  this  method  on  the  thirteenth  day. 
Probably  continuous  cold  irrigation  may  be  found  useful  in  cases  of 
even  longer  duration. 

If  the  opportunity  of  reducing  within  a  fcM^  hours  or  days  be  lost, 
the  difficulty  increases  through  advancing  involution  of  the  uterus  and 
contraction  of  the  os.  Still  the  same  manipulation  may  be  attempted. 
We  must  act  steadfastly  in  the  faith  that  pressure  sufficiently  long  kept 
up  upon  the  os  uteri  Mall  cause  it  to  yield.  It  is  really  a  question  of 
time — too  long  a  time  indeed  for  the  hand  of  the  surgeon  to  work — 
but  not  for  other  mechanical  appliances.  Dr.  Tyler  Smith  is  entitled 
to  the  credit  of  proving  this  point  by  success  (Med.-Chir.  Trans.,  1858). 
In  a  case  of  inversion  of  twelve  years'  standing  he  effected  reduction 
by  maintaining  pressure  upon  the  tumor  and  thus  upon  the  os  by  an 
air-pessary  during  several  days.  Pridgin  Teale  (Med.  Times  and  Gaz., 
1859)  reduced  an  inversion  of  six  months  by  the  air-pessary  in  three 
days.  Dr.  C.  West  (Med.  Times  and  Gaz.,  1859)  by  similar  means 
reduced  an  inversion  of  a  year's  standing.  Dr.  Bockenthal  (Monats- 
schr.  f.  Geburtsk.,  1860)  succeeded  in  six  days  in  reducing  an  inver- 
sion which  had  lasted  six  years.  Mr.  James  Hakes  (Liverpool  Med. 
and  Surg.  Reports,  1868)  by  same  means  reduced  a  chronic  inversion 
in  fourteen  days.  Dr.  Schroeder,  of  Bonn  (Berlin  Klin.  Wochnschr., 
1868)  thus  reduced  an  inversion  of  two  years.  And  latterly  (1869), 
Mr.  Lawson  Tait,  on  my  suggestion,  effected  reduction  in  the  same 
manner.  The  last  woman  died ;  but  her  case  Avas  already  desperate. 
Borggreve,  indeed,  had  applied  the  same  principle.  He  used  a  stem 
eight  inches  long  with  an  egg-shaped  knob  which  he  fitted  to  the  in- 
verted fundus,  and  held  it  in  gentle  pressure  by  a  T-bandage.  In 
three  days  the  uterus  was  returned.  Dr.  Marion  Sims  relates  an  in- 
teresting instance  of  the  influence  of  constant  pressure.  A  stem-pes- 
sary with  an  external  support,  after  pressing  for  some  days  upon  the 
inverted  fundus,  w^s  found  to  be  taken  up  into  the  inside  of  the  re- 
inverted  uterus,  the  os  having  yielded  and  allowed  both  to  pass  in 
together. 

Courty  ("Maladies  de  I'Uterus,"  1866)  relates  a  case  in  which  in- 
version had  existed  ten  months,  inducing  repeated  hemorrhage  and 
extreme  debility.  He  reduced  it  in  the  following  manner.  The  uterus 
was  dragged  outside  the  vulva  by  Museux's  vulsellum ;  then,  the  index 
and  middle  finger  of  the  right  hand  were  passed  into  the  rectum,  and 


TREATMENT.  631 

hooked  forward  over  the  neck  of  the  uterus;  then  the  uterus  was 
seized  with  the  left  hand,  and  passed  back  into  the  vagina;  still  holding 
the  neck  hooked  down,  the  fundus  of  the  uterus  was  turned  so  as  to 
look  forwards  to  the  pubes,  the  neck  turned  to  the  sacrum.  The 
fingers  in  the  rectum  separating,  rest  firmly  in  the  angular  sinuses 
formed  by  the  utero-sacral  ligaments ;  then  the  thumb  and  index  of 
the  left  hand  pressing  on  the  pedicle  of  the  tumor  gradually  increase 
the  depth  of  the  utero-cervical  groove.  The  two  hands  acting  thus  in 
concert,  the  uterus  was  reduced  without  violence  in  a  few  minutes. 
He  had  failed  with  the  air-pessary;  the  patient  could  not  bear  it.  He 
cites  Barrier  (Bull,  de  I'Acad,,  1862)  as  having  reduced  a  case  of  fif- 
teen months'  standing,  who  found  a  point  d'appui  by  pushing  the  neck 
of  the  uterus  against  the  sacrum.  Dr.  Emmet  (Amer.  Journ,  of  Med, 
Sci.,  1866)  succeeded  in  the  following  manner:  He  passed  his  hand 
within  the  vagina,  and  whilst  the  fundus  uteri  rested  in  the  palm,  the 
five  fingers  were  made  to  encircle  the  portion  within  the  cervix,  as  near 
as  possible  to  the  seat  of  inversion ;  whilst  the  portion  Avas  thus  firmly 
grasped,  it  was  pushed  upwards,  and  the  fingers  were  immediately 
afterwards  expanded  to  their  utmost.  This  manipulation,  with  the  aid 
of  the  other  hand  over  the  abdomen,  was  persevered  in  until  the  fundus 
had  passed  within  the  os  uteri.  The  advance  gained  was  in  proportion 
to  the  amount  of  dilatation  accomplished  by  the  spreading  of  the  fin- 
gers, thus  increasing  the  transverse  diameter  of  the  uterus,  and  shorten- 
ing its  long  diameter.  When  the  reduction  had  so  far  advanced  that 
the  fingers  could  not  be  passed  fully  up  to  the  seat  of  the  inversion,  steady 
pressure  was  applied  to  the  fundus  by  the  tips  joined  together,  whilst 
an  increased  effort  was  made  by  the  hand  outside  to  roll  out  the  parts 
by  sliding  the  abdominal  parietes  over  the  edge  of  the  funnel. 

It  has  happened  in  several  cases  that  only  partial  reduction  could  be 
effected ;  that  is,  the  body  would  return  through  the  cervix  in  a  doubled 
form,  the  fundus  still  being  depressed,  and  presenting  just  above  the 
cervix.  In  such  cases,  continuous  steady  support  by  a  cup-shaped 
pessary  or  the  end  of  a  stethoscope,  may  in  time  complete  the  restora- 
tion. This  difficulty  has  been  met  in  an  ingenious  way  by  Dr.  Emmet, 
He  effected  the  closure  of  the  os  externum  by  silver  sutures,  so  that  the 
fundus  imprisoned  in  the  cavity  of  the  neck  tends  to  dilate  the  con- 
striction near  the  os  internum.  At  a  subsequent  period  the  stitches  are 
removed,  and  the  taxis  is  practiced  again. 

Dr.  Emil  Noeggerath,  of  New  York,  has  described  a  method  of 
taxis  which  deserves  attention.  "It  consists  in  compressing  the  uterine 
body  opposite  to  each  horn,  so  as  to  indent  one  of  these,  and  thus  offer 
to  the  cervical  canal  a  wedge,  which  passes  up,  and  is  followed  rapidly 
by  the  other  horn,  and  the  whole  body,"  Thomas  reports  that  he  has 
practiced  this  manoeuvre  on  two  occasions  with  success. 

From  time  to  time  a  method  which  may  be  described  as  the  forcible 
taxis  has  been  employed.  Of  late  years  a  proposition  has  been  made, 
supported  by  several  distinguished  American  physicians,  to  admit  this 
method  to  a  recognized  place  in  the  treatment  of  chronic  inversion.  The 
fact  that  death  after  rupture  of  the  uterus  or  vagina  has  several  times 
been  the  consequence  of  forcible  taxis  should  alone  be  sufficient  to  dis- 


632  INVERSION    OF    THE     UTEEUS. 

credit  the  method.  No  number  of  successes  ought  to  outweigh  failure 
so  deplorable.  Forcible  reposition  has  been  attempted  either  by  the 
hand  alone  or  by  aid  of  a  repoussoir,  that  is,  some  kind  of  blunt  instru- 
ment of  wood  or  ivory.  Depaul  (Gaz.  des  Hop.,  1851)  used  a  repoussoir 
in  a  case  eleven  days  after  labor.  The  patient  died  in  a  few  days  from 
rupture  of  the  uterus.  Laceration  has  also  occurred  in  several  cases  in 
America. 

It  is  true  that  success  restores  the  woman  to  her  former  integrity, 
but  the  penalty  of  failure  to  return  the  uterus  is  not  infrequently  death. 
The  part  will  not  sustain  more  than  a  certain  amount  of  violence  without 
laceration  ;  much  force  is  necessary,  and  it  is  impossible  to  restrict  with 
nicety  the  force  employed  within  safe  limits.  Sustained  solid  or  elastic 
pressure  is  free  from  the  objections  that  surround  the  preceding  methods. 
Success  means  restoration  to  integrity,  and  failure  does  not  mean  death 
or  injury.  It  simply  leaves  the  patient  in  statu  quo,  and  in  a  condi- 
tion to  be  treated  with  every  prospect  of  success  by  the  adjuvant  method 
of  cervical  incisions.  This  method  of  forcible  taxis  has  been  confounded, 
especially  by  some  American  authors,  with  that  of  gradual  reduction 
by  sustained  elastic  pressure.  The  principles  of  the  two  procedures 
are  totally  opposite.  One  tries  to  overcome  resistance  by  sheer  force 
rapidly  applied,  the  other  by  wearing  out  resistance  by  gentle  pressure 
long  sustained.  The  first  is  replete  with  danger,  the  second  almost 
absolutely  safe. 

A  method  of  effecting  reduction  remarkable  for  its  boldness  has  been 
put  in  practice  by  Professor  Thomas.  This  consists  in  making  an 
incision  through  the  abdominal  wall  so  as  to  get  at  the  constricted  os 
uteri  from  above,  and  then  applying  a  dilating  force.  The  idea  was 
enunciated  by  the  late  Sir  James  Simpson  at  the  discussion  of  my  paper 
before  the  Medico-Chirurgical  Society  in  1869.  A  case  in  which  it 
was  carried  out  by  Thomas  is  thus  described  :  An  assistant  introduced 
his  hand  into  the  vagina,  and  "  lifted  the  uterus  so  that  I  could  detect 
the  cervical  ring  against  the  abdominal  wall.  I  then  slowly  cut  down 
upon  the  median  line,  as  for  an  exploratory  incision  in  ovariotomy,  and 
leaving  the  wound  exposed  to  the  air  until  all  oozing  had  ceased,  cut 
into  the  peritoneum.  I  then  inserted  my  finger  into  the  uterine  sac, 
and  found  no  adhesion  whatever  to  exist.  Replacing  the  assistant's 
hand  by  my  left  hand,  I  now  inserted  the  steel  dilator  and  dilated  the 
stricture.  (The  dilator  is  constructed  on  the  principle  of  a  glove- 
stretcher,  R.  B.)  The  dilatation  was  exceedingly  easy  and  rapid,  but 
I  found  that  as  I  withdrew  the  dilator,  the  tissue  of  the  organ  would 
at  once  contract.  After  dilating  the  stricture  fully,  I  partially  returned 
the  uterus.  .  .  .  Drawing  it  down  to  the  vulva,  I  rapidly  pushed  it 
up,  and  was  gratified  at  finding  that  it  was  nearly  replaced.  Drawing 
it  down  again,  this  time  outside  of  the  body,  to  my  dismay  I  discovered 
that  the  artery  cut  one  week  before  was  spouting  freely.  ...  I  rapidly 
returned  the  organ,  and  was  delighted  to  find  one  horn  rise  into  place. 
But  the  additional  force  employed  was  a  little  more  than  the  vagina 
could  bear,  and  one  finger  passed  through  between  the  uterus  and  the 
bladder.  One  horn  was  still  inverted.  Passing  the  dilator  into  this, 
I  stretched  it  open,  and  instantly  the  uterus  resumed  its  normal  posi- 


TREATMENT.  633 

tion.  The  artery  bled  freely  that  day  into  the  vagina  and  into  the 
peritoneum  through  the  vaginal  rent.  But  the  patient  ultimately  re- 
covered." Dr.  Thomas  operated  in  the  same  way  in  another  case. 
"  She  did  perfectly  well  for  forty-eight  hours,  but  at  the  expiration  of 
that  time  peritonitis  developed  itself,  and  proceeded  to  a  fatal  issue." 

Reflection  upon  these  cases  will  hardly,  I  think,  justify  the  recom- 
mendation of  Dr.  Thomas.  In  the  first  case,  even  after  dilatation  of 
the  cervical  ring,  so  much  force  was  necessary  in  taxis  as  to  rend  the 
vagina;  whilst  in  the  second,  fatal  peritonitis  was  the  result.  A  method 
which  requires  gastrotomy  for  its  execution,  involves  conditions  of  dan- 
ger so  great  that  even  amputation  seems  preferable. 

Amputation  may  be  likened  to  catting  the  Gordian  knot.  It  is  an 
apt  illustration  of  John  Hunter's  aphorism.  It  is  a  confession  of  ira- 
potency  to  solve  the  problem  of  reduction.  It  is  the  last  resource;  one 
to  which  I  am  firmly  convinced  we  need  hardly  ever,  if  ever,  be  driven. 
Notwithstanding  the  histories  of  a  considerable  number  of  cases  of  re- 
covery after  the  operation,  it  cannot  be  said  to  take  rank  as  a  scientific 
proceeding.     Recovery  cannot  be  guaranteed. 

The  conditions  of  safety  depending  upon  nature  may  be  absent,  and 
the  surgical  means  at  present  known  are  imperfect.  When  the  uterus 
is  cut  across  at  the  neck,  of  course  a  hole  is  made  opening  from  the 
fundus  of  the  vagina  into  the  peritoneal  cavity.  The  danger  of  fatal 
peritonitis  is  great.  The  shock  of  the  operation  also  is  serious.  Hem- 
orrhage is  likely  to  ensue,  and  some  blood  will  escape  into  the  abdo- 
men. There  are  various  methods  of  performing  the  operation.  The 
uterus  has  been  seized  by  a  vulsellum,  drawn  down,  and  the  cervix 
cut  through  with  a  knife.  Then  it  was  thought  that  the  ligature  ap- 
plied to  strangle  and  to  slough  through,  as  in  the  case  of  a  polypus, 
would  be  less  dangerous.  Treated  in  this  way  the  result  has  been 
varied.  In  several  instances  where  a  whipcord  ligature  has  been  ap- 
plied by  Levret's  or  Gooch's  double  canula,  agony  so  intense  has  been 
produced,  as  to  render  it  necessary  to  remove  the  ligature,  and  the  pa- 
tient has  died  notwithstanding.  The  cause  of  the  excruciating  pain  is,  I 
believe,  the  compression  of  the  included  Fallopian  tubes.  I  have  observed 
the  same  pain  in  cases  when  the  tubes  have  been  tied-in  the  pedicle  of 
an  ovarian  tumor.  And  it  has  been  observed  in  several  cases  that  the 
surface  and  substance  of  the  uterus  proper  was  nearly  insensible,  pain 
being  developed  only  on  tightening  the  ligature.  In  some  cases  the 
patient  has  died  with  the  ligature  attached.  There  is  a  preparation 
illustrating  this  in  the  museum  of  Bartholomew's  Hospital,  death  en- 
suing from  peritonitis  eight  days  after  tying.  On  the  other  hand,  it 
seems  not  unreasonable  to  hope  that  a  ligature  gradually  tightened 
may  set  up  adhesive  inflammation  in  the  neighboring  peritoneum,  and 
thus  shut  off  the  abdomen  from  communication  with  the  vagina  when 
the  uterus  falls  away.  Certain  it  is  that  this  hope  is  not  always  re- 
alized. Thus  Dr.  McClintock  (opits  cited.)  relates  a  case  in  which  a  liga- 
ture was  applied  during  eighteen  days,  occasionally  relaxing  it  on  ac- 
count of  the  severity  of  the  pain,  before  the  uterus  was  separated.  No 
peritoneal  adhesion  had  taken  place;  the  woman,  however,  made  a 
good  recovery.     In  eighteen  cases  where  the  time  that  elapsed  before 


634  INVERSION    OF    THE    UTERUS. 

the  uterus  fell  is  stated,  the  ligature  took  from  nine  to  twenty-eight 
days  to  sever  the  parts.     The  average  time  was  seventeen  days. 

It  has  been  remarked  that  the  ligature  has  arrested  the  hemorrhage. 
Dr.  Ramsbotham  lias  related  a  case  in  which  the  ligature  had  to  be 
removed  at  the  end  of  twenty-four  hours,  owing  to  symptoms  of  vio- 
lent peritonitis ;  but  the  profuse  sanguineous  and  mucous  discharges 
ceased. 

Mr.  J.  G.  Forbes  (Med.-Chir.  Trans.,  vol.  xxxv)  suggests  that  the 
simple  application  of  a  ligature  around  the  neck  of  the  tumor  to  de- 
stroy its  vitality  appears  to  possess  more  advantages  than  the  other 
modes  of  operating. 

Dr.  INIcClintock  relates  two  cases  in  which  strangulation  was  first 
effected  by  a  ligature  for  four  days,  and  then  the  uterus  was  removed 
below  the  ligature  by  the  chain -^craseur.  The  patients  recovered. 
This  combined  method  seems  likely  to  unite  most  conditions  of  suc- 
cess. Dr.  Marion  Sims  relates  (op.  cit.)  a  case  in  which,  after  vain  at- 
tempts at  reduction,  and  being  compelled  by  the  consequent  pain  and 
prostration  to  abandon  the  ligature,  he  resorted  to  the  chain-ecraseur. 
When  the  parts  were  all  divided  except  the  right  broad  ligament,  "all 
at  once  the  most  fearful  hemorrhage  he  ever  encountered  took  place." 
It  was  happily  stopped  by  passing  the  finger  into  the  abdominal  open- 
ing and  compressing  the  source  of  the  hemorrhage.  The  blood  which 
had  escaped  into  the  peritoneal  cavity  was  sponged  out,  and  the  divided 
edges  of  the  cervix  were  united  by  five  or  six  silver  sutures.  The  pa- 
tient recovered.  Mr.  Baker,  of  Birmingham,  relates  (Brit.  Med.  Jour., 
1868)  a  case  of  recovery  after  amputation  by  the  chain-ecraseur.  The 
bleeding  vessels  were  sealed  by  actual  cautery.  Dr.  Hall  Davis  relates 
(Obstetrical  Transactions,  1873)  a  case  in  which  he  amputated  the  uterus 
ten  months  after  labor.  He  used  the  single  wire  ecraseur.  He  em- 
ployed it  without  first  dragging  upon  the  neck  of  the  uterus,  expecting 
thus  to  lessen  the  risk  of  the  sudden  springing  up  into  the  peritoneal 
cavity  of  the  severed  cervical  portion  of  the  uterus.  No  hemorrhage 
occurred.  The  patient  recovered.  Pain  was  subdued  after  the  opera- 
tion by  subcutaneous  injection  of  morphia  every  six  hours  during  the 
first  twelve  days-,  it  being  found  that  any  suspension  of  its  use  was  fol- 
lowed by  severe  uterine  and  ovarian  pains.  The  pulse  was  vei;^  small 
immediately  after  the  operation,  and  the  temperature  fell  to  97°  F.  It 
appeared  that  in  this  case  there  were  peritoneal  adhesions,  a  condition 
which,  no  doubt,  supplied  a  safeguard  against  peritonitis,  and  which, 
as  it  would  have  rendered  reduction  impossible,  justified  the  recourse 
to  amputation.  Professor  Barba  (II  Morgagni,  1872)  amputated  an 
inverted  uterus  of  three  months'  standing  by  Chassaignac's  ecraseur. 
There  was  no  great  bleeding;  but  syncope  set  in  immediately,  and 
lasted  seven  hours.  This  was  followed  by  peritonitis,  which  subsided 
in  fourteen  days.     The  patient  recovered. 

Dr.  Valette  (Lyon  Medical,  1871)  relates  a  case  of  successful 
amputation  by  means  of  a  clamp,  each  blade  of  which  was  grooved  to 
carry  chloride  of  zinc  paste.  The  neck  of  the  tumor  being  seized  in 
this  caustic  clamp,  the  uterus  was  cut  off  in  front  of  it,  and  the  stump 


TREATMENT.  635 

cauterized  with  chloride  of  zinc.  The  actual  cautery  would  give 
greater  security  against  hemorrhage. 

The  preceding  histories  will  show  some  of  the  dangers  attending 
amputation,  and  how  they  may  best  be  encountered.  In  those  rare  cases 
where  adhesions  or  extreme  exhaustion  forbid  the  attempt  to  reduce, 
the  best  method  of  amputation  appears  to  be  by  the  wire-ecraseur.  The 
induction  of  ansethesia  is  of  course  indispensable.  Were  I  compelled  to 
resort  to  this  ultima  ratio,  I  should,  before  amputation,  transfix  the  neck 
of  the  tumor  by  a  needle  carrying  a  wire  suture,  so  as  to  command  the 
divided  edges  of  the  opening,  and  facilitate  the  application  of  the  cau- 
tery to  the  bleeding  surface.  The  use  of  the  galvanic  cautery  wnre  to 
effect  the  amputation  seems  to  possess  advantages  over  the  other  forms 
of  ecraseur. 

In  cases  wdiere  neither  reduction  nor  ablation  can  be  attempted, 
hemorrhage  and  other  discharges  may  be  restrained  by  lotions  of  tan- 
nin, alum,  perchloride  or  persulphate  of  iron,  or  of  carbolic  acid;  and 
probably  some  advantage  may  be  derived  by  compressing  the  uterus 
by  wearing  an  air-pessary  in  the  vagina. 

In  my  memoir  in  the  Medico-Chirurgical  Transactions,  1869, 1  gave 
a  summary  account  of  the  results  which  had  attended  the  various 
modes  of  operating  in  the  cases  which  I  had  then  been  able  to  collect. 
Further  research,  and  the  records  of  subsequent  histories,  some  of  which 
are  referred  to  in  the  two  preceding  pages,  involve  some  modification 
of  the  conclusions  then  arrived  at.  But  the  practical  lessons  flowing 
from  this  summary  are  still  valid. 

"  Six  different  modes  of  dealing  with  ehronio  inversion  have  been 
tried  with  the  following  results  in  the  cases  I  have  been  able  to  examine. 

"  I.  By  ligature  alone.  Of  these  twenty -six  were  successful,  ten 
unsuccessful.  Of  the  unsuccessful  eight  died,  and  two  recovered 
without  extirpation. 

"  II.  By  ligature  and  excision :  nine  were  successful,  three  unsuc- 
cessful.    These  three  all  died. 

"  III.  By  excision  simple  :  three  were  successful,  two  died. 

"  IV.  By  sustained  solid  pressure  there  have  been  several  successful 
cases. 

"V.  By  sustained  elastic  pressure  in  eight  cases  the  uterus  w^as 
restored ;  in  seven  of  them  recovery  was  perfect,  one  died,  being 
already  beyond  hope.  In  three  or  four  cases  reported,  the  pressure 
was  given  up. 

"  VI.  By  forcible  taxis :  six  successful  cases  are  reported ;  four 
failed,  all  of  them  dying." 

In  appreciating  the  relative  merits  of  these  different  operations  it 
must  be  remembered  that  the  highest  success  attained  by  ligature  or 
excision  is  achieved  at  the  cost  of  mutilation;  the  woman  is  unsexed; 
and  failure  commonly  means  death. 

The  following  passage  is  quoted  from  my  memoir  above  referred 
to: 

"  Another  proceeding  stands  before  amputation.  For  twenty  years 
I  have  taught  in  my  lectures  that  the  unyielding  cervix  may  be  divided 
by  incisions  carried  into  its  substance  from  above  downwards  at  different 


636 


INVERSION    OF    THE    UTERUS. 


points  of  its  circumference.  Pressure  then  applied  will  cause  it  to  yield 
more  easily.  Huguier,  Professor  Simpson,  and  Dr.  Marion  Sims  have 
suggested  the  same  plan. 

"  I  am  not  aware  that  it  had  ever  been  carried  into  execution  before 
1868,  when  I  treated  a  case  in  this  manner  with  complete  success. 
The  inversion  was  complete ;  it  had  lasted  six  months ;  the  patient  was 
so  prostrate  from  continuous  discharges  that  the  prospect  of  her  holding 
out  many  weeks  was  small.  I  first  tried  to  rein  vert  by  keeping  up 
continuous  elastic  pressure  during  five  days,  with  occasional  attempts 
by  taxis  as  recommended  by  Tyler  Smith.  This  failing,  I  drew  down 
the  tumor  to  the  vulva  by  passing  a  sling-noose  of  tape  round  it,  thus 
putting  the  neck  on  the  stretch  (see  Fig.  137);  T  then  made  three 


Dr.  Barnes's  operation.    Showing  inverted  uterus  drawn  down  by  tape-noose. 
ab  c.    Line  of  incisions  in  the  cervix. 


incisions  in  the  neck  about  a  third  of  an  inch  deep,  one  on  each  side 
and  one  behind  in  a  longitudinal  direction,  that  is,  across  the  fibres  of 
the  cervical  sphincter.  Then,  compressing  the  uterus  with  my  left 
hand,  and  supporting  the  os  uteri  by  the  fingers  of  the  right  hand 
through  the  abdominal  wall,  I  found  the  cervix  yield,  and  the  body 
went  through  into  its  place.  The  cervix  yielded  by  laceration  extend- 
ing from  the  incisions  ;  and  I  very  much  feared  at  the  time  that 
serious  if  not  fatal  mischief  had  been  done.  No  material  incon- 
venience, however,  followed ;  and  examination  three  weeks  afterwards 
showed  the  cervix  and  uterus  to  be  in  their  proper  places.  Notwith- 
standing the  successful  issue,  I  believe  that  the  method  should  only  be 
resorted  to  after  a  full  trial  of  Tyler  Smith's  plan,  and  then  with  great 
caution.     I  should  recommend  that  only  two  incisions  be  made,  one  on 


TREATMENT.  637 

each  side  of  the  os,  and  these  of  moderate  depth.  The  rein  version 
should  be  trusted  to  sustained  elastic  pressure." 

This  suggestion  I  have  since  had  the  good  fortune  to  carry  out  with 
complete  success.  I  have  narrated  the  history  in  a  memoir  in  the  first 
number  of  the  Obstetrical  Journal  (1873).^  The  first  woman  has  had 
two  children  since  the  operation.  The  operation,  then,  has  been  twice 
successful.  Coming  in,  as  it  does,  as  supplementary  to  the  plan  of  sus- 
tained elastic  pressure,  extending  the  application  of  this  plan,  its  value 
is  incontestable.  The  evidence  of  experience,  as  well  as  of  physiological 
reasoning,  is  now  so  strong  that  we  can  rarely  be  justified  in  resorting 
to  the  ultimate  remedy,  one  full  of  danger,  of  amputating  the  inverted 
uterus. 

Professor  Thomas  reports  a  case  in  which  he  incised  the  cervix  as 
follows  ("  Diseases  of  Women,"  1872).  In  June,  1869,  attempts  by 
taxis  having  failed,  "I  pushed  the  uterus  as  far  as  it  would  go;  thus 
fixing  by  my  finger  the  point  of  constriction,  I  drew  it  down,  and  cut 
down  through  the  neck,  the  incision  first  involving  the  mucous  mem- 
brane, and  extending  down  toward  the  subjacent  peritoneum,  as  recom- 
mended by  Aran.  No  sooner  was  the  knife  withdrawn  than  a  free  jet 
of  blood  was  projected  from  an  artery  which  appeared  nearly  equal  in 
size  to  the  radial.  This  jet  was  not  per  saltum,  but  steady,  as  it  is  often 
seen  to  be  from  small  arteries  located  in  dense  fibrous  tissue.  For  half  an 
hour  we  strove  to  ligate  this.  Upwards  of  a  dozen  ligatures  were  one 
after  another  applied,  but  the  vessel  had  retracted  into  the  brittle  tis- 
sue of  the  uterus  and  could  not  be  tied.  The  flow  was  at  last  checked 
by  passing  a  suture  through  both  of  the  wounds  and  bringing  them 
forcibly  together."  This  is  the  case  which  was  completed  by  Thomas's 
plan  as  described  at  page  632. 

The  application  of  sustained  elastic  pressure  requires  care  and  watch- 
ing. The  distress,  even  pain,  occasioned  by  the  ccmtinuous  distension 
is  severe;  and  in  several  cases  it  has  been  felt  necessary  to  abandon  the 
method.  To  obviate  this  difficulty,  the  pressure  may  be  occasionally 
relaxed ;  and  we  may  have  recourse  to  chloral  or  the  subcutaneous  in- 
jection of  morphia.  The  proceeding  undoubtedly  requires  steady  per- 
severance and  some  skill  in  adjusting  and  regulating  the  pressure.  But 
these  conditions  given,  success  will  rarely  be  wanting. 

The  best  Time  for  attempting  Heduction. — Sometimes,  as  when  the 
symptoms  are  very  urgent,  we  have  no  choice.  But  where  the  oppor- 
tunity is  given,  it  would,  I  think,  be  better  to  work  between  the  men- 
strual epochs,  observing  the  general  rule  to  avoid  operations  during 
menstruation.  Malgaigne,  however,  preferred  a  menstrual  period,  on 
the  ground  that  at  this  time  the  tissues  are  softer  and  more  yielding. 

In  my  second  case  I  used  the  elastic  pessary  (Fig.  138).  It  consists 
of  a  fixed  stem  made  to  fit  the  pelvic  curve,  and  surmounted  with  a 
cup-shaped  disk  of  hollow  rubber  which  receives  the  inverted  uterus. 
At  the  end  of  the  stem,  which  is  outside  the  vulva,  are  attached  strong 
rubber  bands  which  are  brought  up  before  and  behind  to  be  attached 
to  an  abdominal  belt.     By  means  of  these  bands  the  difficulty  of  main- 

1  "  On  a  New  Method  of  Reducins;  Chronic  Inversion  of  the  Uterus." 


638 


INVERSION    OF    THE     UTERUS. 


taining  steady  pressure,  which  occurs  when  inflated  bags  are  used,  is 
entirely  obviated.  By  tightening  or  relaxing  these  bands  it  is  easy 
not  only  to  regulate  the  pressure  to  a  nicety,  but  also  to  give  it  the 
exact  direction  we  want.  For  example,  by  bracing  up  the  posterior 
bands  we  throw  the  force  forwards,  and  may  spend  it  directly  upon  the 


Dr.  Barnes's  elastic  pessary  for  reduction  of  chronic  inversion  of  the  uterus. 

neck  of  the  tumor.  Thus  pulling  upon  the  ring  of  reflection,  there  is 
kept  up  a  constant  eccentric  pull  tending  to  open  the  constriction. 
The  pressure  upon  the  body  of  the  uterus  at  the  same  time  tends  to 
press  out  the  blood  and  serum  from  its  tissues,  diminishing  its  bulk 
and  arresting  hemorrhage.  Counter-pressure  should  be  exerted  by 
pads  to  the  abdomen  supported  by  a  firm  binder. 

Once  a  day,  or  every  other  day,  the  instrument  may  be  removed, 
and,  under  chloroform,  an  attempt  at  reduction  by  taxis  may  be  made. 
For  this  purpose  one  hand  should  be  passed  into  the  vagina,  whilst  the 
other  hand  applied  above  the  pubes  exerts  counter-pressure  upon  the 
funnel-like  ring  of  the  inverted  organ.  The  fingers  grasping  the  neck 
of  the  tumor,  alternately  compressing  and  pushing  at  the  circumference, 
we  persevere  either  until  we  feel  the  ring  expanding  and  a  part  of  the 
mass  going  through  it,  or  until  fatigue  or  the  condition  of  the  patient 
warn  us  to  desist.  In  the  latter  case  we  readjust  the  elastic  pessary. 
In  the  former  case  the  reduction  is  commonly  effected  at  last  suddenly; 
we  feel  the  fundus  go  into  its  place  with  a  jerk.  The  restored  cavity 
of  the  uterus  should  then  be  swabbed  with  a  solution  of  iron,  and  the 
patient  left  to  rest. 


TUMORS    OF    THE     UTERUS.  639 

When  well  adapted  and  steadily  pursued  attempts  to  reduce  have 
failed,  and  the  patient's  life  is  threatened,  then  only  shall  we  be  justified 
in  resorting  to  the  anceps  remedium  of  amputating  the  offending  organ. 

When  attempts  at  reduction  have  failed,  the  operators  have  in  some 
cases  been  too  ready  to  conclude  that  the  cause  of  failure  lay  in  adhe- 
sions. But  it  is  remarkable  how  seldom  this  conjecture  has  been  borne 
out  by  facts.  The  truth  is  that  adhesions  are  extremely  rare.  It  has 
even  been  difficult  to  produce  them  by  proceedings  directed  ad  hoe  in 
order  to  obviate  some  of  the  dangers  of  amputation.  The  possibility 
then  of  adhesions  opposing  reduction  may  be  practically  disregarded 
if  gradual  elastic*  pressure  be  employed. 


CHAPTER  XL VII. 

TUMORS  OF  THE  UTERUS;  MALIGNANT  AND  NON-MALIGNANT; 
FIBROID  OR  MYOMA;  DESCRIPTION  OF  FIBROIDS,  THEIR 
NATURAL  HISTORY,  RISE,  PROGRESS,  AND  TERMINATIONS; 
VARIETIES  OF  FIBROID  TUMORS;  THE  DIFFUSE  TUMOR;  THE 
FIBRO-CYSTIC  ;  THE  RECURRENT  FIBROID;  THE  ERECTILE 
TUMOR  OF  CARSWELL;  THE  DEVELOPMENT  AND  DECAY  OF 
FIBROIDS;  EFFECTS  OF  FIBROIDS  UPON  THE  UTERUS  AND 
SURROUNDING  ORGANS  AND  SYSTEM  GENERALLY";  THE 
SYMPTOMS  AND  DIAGNOSIS;  THE  TREATMENT. 

Alike  for  pathological  and  clinical  study,  new  growths  or  tumors 
in  the  uterus  may  be  divided  into  malignant  and  non-malignant. 
Although  there  are  forms  of  transitional  character  which  it  may  be 
difficult  to  refer  with  absolute  certainty  to  one  or  the  other  class,  it  is 
still  convenient  to  observe  this  distinction  as  far  as  we  can.  Thus  I 
propose  to  devote  one  chapter  to  non-malignant  tumors,  and  another  to 
the  malignant  diseases  generally  associated  under  the  common  name 
of  "  cancer." 

Non-malignant  tumors  are  classified  first,  according  to  their  histo- 
logical characters ;  secondly,  according  to  their  seat  or  other  clinical 
characters.  It  may  be  stated  as  a  proposition  generally  true  that  non- 
malignant  tumors  affect  the  body  of  the  uterus,  and  malignant  growths 
affect  the  cervix.  But  in  accepting  this  statement  we  must  be  careful 
in  practice  not  to  forget  that  there  are  many  exceptions.  In  most  cases 
the  seat  of  the  tumor,  malignant  or  non-malignant,  exerts  a  material 
influence  upon  the  clinical  history,  and  often  influences  treatment. 


640  FIBROID    TUMOR    OF    THE    UTERUS. 

Fibroid  Tumors. — There  is  perhaps  no  organic  change  in  the  uterus 
more  common  than  the  development  of  tumors  of  this  character.  The 
statement  of  Bayle  that  20  per  cent,  of  all  women  dying  after  the  age 
of  thirty-five  have  fibroid  tumors  in  the  uterus  is  always  quoted  in  > 
reference  to  this  point ;  and  Klob,  a  more  recent  writer,  says,  "  Un- 
doubtedly 40  per  cent,  of  the  uteri  of  women  who  die  after  the  fiftieth 
year  contain  fibroid  tumors."  Although  unable  to  oppose  these  state- 
ments with  numerical  deductions,  I  venture  to  doubt  whether  the  fre- 
quency of  this  affection  is  so  great  as  these  figures  would  indicate. 
Admitting  their  approximate  accuracy,  two  conclusions  are  sufficiently 
justified.  First,  in  a  large  proj)ortion  of  cases  fibroid  tumors  in  the 
uterus  occasion  no  marked  distress,  and  entail  little  danger  to  health  or 
life ;  secondly,  they  occur  with  increasing  frequency  with  the  advance 
of  age  until  the  climacteric  is  reached.  1  do  not  know  that  it  has  ever 
been  clearly  made  out  that  fibroid  tumors  originate  after  the  climacteric. 
Undoubtedly  they  may  grow  after  this  epocli,  and  that  very  rapidly, 
but  the  time  of  their  formation  is  mainly,  if  not  absolutely  limited  to 
the  period  of  sexual  activity. 

Cruveilhier  called  attention  to  the  remarkable  affinity  of  the  uterus 
for  these  fibroid  bodies.  It  must  also  be  borne  in  mind  that  similar 
tumors  form  wherever  there  is  muscle  resembling  that  of  the  uterine 
wall.  Thus  they  are  found  in  the  broad  ligament,  and  in  the  vagina. 
Although  far  more  frequent  in  the  body  of  the  uterus,  where  the  mus- 
cular element  preponderates,  they  occasionally  arise  in  the  cervix. 
Indeed,  there  is  a  form  of  fibroid  degeneration  which  seems  especially 
to  affect  the  cervix,  producing  thickening  of  some  portion  of  its  wall, 
generally  the  anterior.  This  form,  however,  is  not  identical  with  the 
common  fibroid ;  it  is  not  distinctly  capsulated.  But  tumors  in  all 
respects  resembling  the  true  fibroids  do  occur  in  the  cervix.  Thus 
Professor  Faye  in  an  elaborate  memoir  (Christiania,  1866)  on  inflam- 
matory hypertrophic  and  fibrous  tumors  of  the  cervix  uteri,  relates  in 
detail  a  case  of  unusually  large  fibrous  tumor  growing  from  the  anterior 
lip  of  the  vaginal-portion.  I  have  seen  several  such  cases  assuming  a 
polypoid  condition.  I  have  also  removed  several  from  the  vagina 
quite  separate  from  the  uterus.  Dr.  Honing  (Berlin.  Klin.  Wochenschr., 
1869)  relates  the  case  of  a  woman  aged  forty-one,  who  suffered  from 
dysuria  and  bowel-obstruction.  A  tumor  the  size  of  the  fist  projected 
from  the  genitals;  it  sprang  from  the  left  side  of  the  urethra.  A  still 
larger  tumor  was  contained  in  the  vagina.  The  mass  was  a  "soft 
fibroid." 

The  various  names  given  to  these  growths  attest  the  varying  ideas 
that  have  been  current  as  to  their  nature.  Baillie  called  them 
"  hard  tubercles  ;"  Hooper,  "  subcartilaginous ;"  then  they  were  called 
"fibrous ;"  to  this  name  succeeded  the  one  in  common  use,  "  fibroid,"  or 
"fibroma;"  and  some  insist  that  "myoma"  and  "fibro-myoma"  are 
more  correct  designations ;  M'hilst  Broca,  regarding  the  similitude  of 
their  structure  with  that  of  the  uterus,  proposes  the  name  "  hysteroma." 
Cruveilhier  observed  that  there  were  "  hard  polypi,  which  consisted  in 
hypertrophy  of  the  tissue  of  the  uterus — such  is  the  one  figured  pi.  vi, 
liv.  xi*"  of  his  work — and  others  consisting  of  fibrous  bodies  developed 


NATURE.  641 

under  the  uterine  mucous  membrane."  The  celebrated  French  pathol- 
ogist thus  describes  the  structure  of  the  polypus  referred  to :  "  The 
figure  represents  an  antero-posterior  section  of  the  polypus  and  of  the 
fundus  of  the  uterus.  The  tissue  of  the  polypus  is  seen  to  be  continu- 
ous, without  any  line  of  demarcation,  with  the  proper  tissue  of  the 
uterus ;  it  is  a  prolongation  of  this  proper  tissue,  and  not  a  fibrous 
body  developed  in  the  thickness  of  the  uterus,  capable  of  being  sepa- 
rated by  enucleation.  The  identity  between  the  tissue  of  the  uterus 
and  the  tissue  of  the  polypus  is  such  that  the  closest  examination  does 
not  reveal  the  slightest  difference." 

Cruveilhier  does  not  appear  to  have  suspected  that  the  ordinary 
fibroid  tumor,  distinctly  defined  from  the  ]3roper  uterine  tissue,  and 
capable  of  enucleation,  might  also  consist  of  muscular  fibre,  in  every 
respect  resembling  the  muscular  fibre  of  the  uterus. 

VogeP  was  one  of  the  first  to  demonstrate  the  essential  identity  of 
structure  of  the  "  fibrous  "  tumor  with  that  of  the  muscular  wail  of  the 
uterus  in  which  it  takes  its  origin.  One  case  (Fig.  8  in  Yogel's  work) 
exhibits  the  "  mature  fibres  of  a  fibrous  tumor  of  the  uterus  found  in  the 
body  of  a  woman  who  died  of  puerperal  fever.  In  the  fundus  uteri  two 
tumors  of  the  size  of  almonds  were  found  externally  projecting  under 
the  peritoneum.  They  consisted  of  jDarallel  fibres,  forming  a  thick, 
very  dense,  milk-white  tissue.  The  fibres  became  pale,  and  gradually 
dissolved  in  acetic  acid  ;  most  of  them  were  long,  spindle-shaped  cells, 
which  were  not  affected  by  acetic  acid.  The  normal  substance  of  the 
uterus  consisted  of  like  fibres,  resembling  in  every  respect  those  of  the 
two  tumors." 

Vogel  gave  several  other  illustrations  of  the  muscular  nature  of 
uterine  fibres,  and  further  established  their  histological  affinity  by 
showing  the  muscular  character  of  fibrous  tumors  found  in  other  parts 
of  the  body.  I  have  cited  the  above  passage  because  the  observation 
it  refers  to  was  made  upon  a  puerperal  uterus.  In  1844  (Guy's  Hos- 
pital Reports)  Dr.  Oldham  described  the  constitution  of  a  polypoid 
mass  which  was  driven  down  by  the  uterus  after  labor.  "The  prevail- 
ing tissue  was  a  clear  unstriped  fibre,  which,  when  examined  with  a 
portion  of  the  muscular  fibre  of  the  uterus,  differed  only  in  the  latter 
being  more  full  of  cells  and  blood-corpuscles,  which  rendered  its  defi- 
nition as  fibre  less  distinct  than  the  former." 

In  February,  1851,  I  had  an  opportunity,  in  conjunction  with  Dr. 
Hassall,  of  verifying  this  identity  of  structure  between  fibrous  tumors 
and  the  uterus  in  the  non-pregnant  state.  (Lancet,  vol.  i,  1851.)  The 
specimen  was  exhibited  to  the  London  Medical  Society.  This  entirely 
confirmed  the  observations  already  cited.  Lebert,  in  1852,  describes 
these  tumors  as  consisting  of — 1.  Cellular  tissue  and  fibro-plastic  ele- 
ments ;  2.  Muscular  fibre-cells  like  those  of  the  uterus ;  these  come  out 
clearly  with  acetic  acid.  On  the  19th  April,  1853,  Dr.  Bristowe  re- 
ported to  the  Pathological  Society  the  result  of  his  examination  of  two 
fibrous  tumors.  Robin  says  "the  muscular  fibre-cells  are  larger  than 
those  of  the  empty  uterus,  but  smaller  than  in  the  gravid  womb ;  that 


Erlaiiterungstafeln  zur  puLliol.  Histologic,"  1843. 
41 


642 


FIBEOID     TUMOR    OF    THE    UTERUS. 


they  constitute  from  one-quarter  to  one-half  of  the  morbid  mass ;  that 
there  is  also  a  large  ])roportion  of  finely  granular  amor])hous  matter, 
very  tenacious,  half  solid,  binding  the  fibres  of  tlie  cellular  tissue,  and 
also  the  fibre-cells  together."  The  granular  amorphous  element  tends 
to' increase  in  proportion  to  the  rapidity  of  the  growth  of  the  tumor. 
I  am  indebted  to  Mr.  Henry  Arnott  for  the  following  illustration  of 
the  structure  of  the  uterine  fibroid  or  myoma : 


Fig.  139. 


k  2  2  0 

structure  of  fibroid  of  uterus. 
Showing  structure  of  waving  hands  of  the  long  spindle-cells,  with  rod-shaped  nuclei  of  plain  muscu- 
lar tissue  ;  the  nuclei  stained  with  carmine.    At  one  point  a  lew  cells  divided 
transversely.     (Ad.  nat.,  by  H.  Arnott.) 

The  similarity  of  constitution,  then,  of  "fibrous"  tumors  with  tliat 
of  the  muscular  wall  of  the  uterus  in  which  they  originate  is  now 
amply  determined.  But  I  think  this  similarity  is  somewhat  over- 
strained. We  do,  indeed,  find  the  same  histological  elements ;  but 
certainly  they  are  combined  in  different  proportions,  so  as  to  produce 
marked  differences  in  some  of  the  physical  characters.  For  example, 
the  "fibroid"  tumor  is  commonly  pearly  white,  more  striated,  under 
the  knife  it  gives  a  different  sensation;  compared  with  the  uterine  wall 
in  which  it  is  imbedded,  its  density  and  feel  are  different ;  its  interior 
is  less  vascular;  it  behaves,  in  short,  in  many  respects  as  a  foreign  body. 
It  is  true  that  in  the  pregnant  uterus  it  follows  to  some  extent  the  same 
laws  of  development  and  of  involution  as  the  muscular  wall;  but  even 
in  this  circumstance,  remarkable  differences  arc  occasionally  observed, 
especially  in  the  course  of  involution.  The  fibroid  tumor  being  less 
one  with  the  uterine  wall,  being  less  vascular,  does  not  always  follow 
jyari  passu  the  retrogression  of  the  proper  muscular  tissue.  It  some- 
times remains  larger.  And  sometimes,  having  less  vitality,  less  power 
of  resistance  to  injury,  it  pas.ses  into  a  state  of  low  inflammation,  or 
necrosis,  which  leads  to  it§  death,  entailing  either  total  disappearance 


POSITION     AND    SHAPE.  643 

by  absorption,  or  the  spread  of  inflammation  to  the  proper  structures 
of  the  uterus,  and  pyaemia.  This  is  especially  liable  to  happen  when 
such  a  tumor  being  situated  in  the  lower  zone  of  the  uterus  is  exposed 
to  unusual  contusion  by  the  passage  of  the  head  during  labor.  The 
process  of  extrusion  is  further  facilitated  by  the  slightness  of  the  at- 
tachments by  which  these  tumors  are  connected  with  the  uterine  wall. 

I  believe,  however,  that  the  chief  factor  in  extrusion  is  not  in  all 
cases  active  uterine  contraction.  It  is  sometimes  the  result  of  the  dif- 
ferent ratio  of  growth  of  the  tumor  and  of  the  uterus.  A  dense,  solid 
substance,  isolated  from  the  uterine  wall  in  which  it  is  imbedded,  and 
continuing  to  grow,  whilst  the  uterus  itself  partakes  but  slightly  in  the 
process  of  enlargement,  will  in  time  form  a  projection  upon  the  one  or 
the  other  surface  of  the  organ.  And  further  growth  will  cause  it  to 
bulge  more  and  more ;  thus  growing  out  of  the  uterus,  rather  than 
being  expelled  from  it. 

Looking  at  the  histological  characters  of  fibroid  tumors  we  may  im- 
agine them  to  arise  from  accidentally  aberrant  growths  of  points  of  the 
original  muscular  structure  of  the  uterus,  that  get  surrounded  by  con- 
nective tissue  or  the  regularly  disposed  muscular  fibres,  and  thus  be- 
come isolated  in  masses  instead  of  being  disposed  in  strata  in  the  gen- 
eral structure. 

The  position  of  fibroid  tumors  varies  infinitely.  Beginning  in  the 
substance  of  the  muscular  wall,  they  are  all  at  first  interstitial.  As 
they  increase  in  size  they  tend  to  bulge  out  either  on  the  outer  or  inner 
surface  of  the  uterus.  In  the  first  case  they  are  called  subperitoneal ; 
in  the  second,  submucous.  They  are  far  more  common  in  the  body  of 
the  uterus  than  in  the  neck.  This  may  be  accounted  for  by  the  lesser 
proportion  of  muscular  fibres  in  the  neck. 

In  shape  fibroids  vary  greatly.  All  are  at  first  probably  rounded, 
and  whilst  single  and  of  moderate  size  they  generally  remain  so.  The 
irregular  nodulated  tumors  are  mostly  conglomerates  of  many  nuclei 
growing  together  at  different  rates.  When  the  tumors  are  separate, 
they  may  by  mutual  compression  assume  various  shapes. 

The  rate  of  growth  is  hard  to  determine.  It  is  not  uniform.  It  is 
governed  greatly  by  the  ovarian  stimulus.  Probably  the  intramural 
or  subperitoneal  tumors  grow  more  slowly  than  the  submucous.  Many 
are  comparatively  small  and  inert  for  many  years.  That  their  usual 
rate  of  growth  is  slow  may  be  interred  from  their  structure,  which  is 
but  scantily  supplied  with  bloodvessels ;  from  the  fact  that  fibroid 
tumors  of  considerable  size  are  rare  in  young  women ;  and  in  many  it 
is  a  matter  of  observation.  I  have  several  women  under  observation 
in  whom  the  existence  of  fibroids  in  the  uterus  was  established  many 
years  ago.  It  is  almost  exclusively  in  women  approaching  or  after  the 
climacteric  that  very  large  tumors  are  seen. 

Fibroid  tumors  are  single  or  multiple,  and  some  tumors  apparently 
single  are  really  compound,  that  is,  conglomerates  of  single  tumors.  The 
characteristic  of  a  single  tumor  is  that  it  consists  of  one  bundle  or  mass ; 
in  the  case  of  multiple  tumors  there  are  two  or  more  masses  situated 
apart  from  each  other  in  distinct  parts  of  the  uterus ;  whilst  conglom- 


644 


FIBROID    TUMOR    OF    THE    UTERUS. 


erate  tumors  consist  of  several  masses  packed  together  in  close  approxi- 
mation. 

There  is  scarcely  a  limit  to  their  number.  In  size  they  vary  from  a 
pin's  head  to  that  of  a  man's  head,  or  even  bigger. 

Examples  of  the  single  and  multiple  tumors  are  seen  in  Figs.  141, 
144. 

Fig.  140. 


Conglomerate  of  fibroid  tumors  of  uterus.    (Two-thirds  nat.  size,  St.  Thomas's  Hospital.) 


Fig.  140,  taken  from  a  specimen  in  St.  Thomas's  Museum,  is  a 
beautiful  illustration  of  the  conglomerate  form.  Each  constituent  mass 
appears  surrounded  in  a  separate  matrix,  whilst  all  are  encapsuled  in 
uterine  tissue. 

Law  of  Gh'owth  of  Iluscular  Tumors  and  Polypi. — The  mode  of 
growth  of  these  tumors,  by  the  development  of  unstriped  muscular 
fibre  from  nuclei,  is  sufficiently  shown  by  the  description  and  figures 
of  Professor  Vogel.  But,  whilst  their  histological  formation  seems  to 
be  similar  to  that  of  the  true  uterine  tissue,  they  appear  to  enjoy  a 
certain  amount  of  independent  developmental  force.  This  is  proved 
by  their  greater  compai^ative  rapidity  of  growth,  and  by  the  fact  that 
they  sometimes  attain  a  very  large  size  in  the  unimpregnated  uterus — 
that  is,  during  a  time  when  the  uterus  itself  scarcely  enlarges  at  all,  or 
only  so  much  as  may  be  attributed  to  the  morbid  stimulus  imparted  by 
the  presence  of  the  tumor.  At  the  same  time  it  is  worthy  of  remark 
that  fibrous  tumors  are  very  rarely  found  before  the  age  of  puberty  ; 
if  they  are,  they  remain  passive  until  the  period  of  activity  of  the 
generative  system.  After  the  childbearing  period,  and  the  cessation 
of  menstruation,  fibrous  tumors  previously  existing  exhibit  a  marked 
tendency  to  recede.  It  is,  I  believe  a  very  rare  occurrence  to  observe 
that  any  fresh  tumors  become  developed  after  this  epoch.  The  period 
of  active  growth  of  fibroid  tumors  and  polypi  is  the  period  of  func- 
tional   activity  of  the  generative  organs.      The    periods   of  greatest 


GROWTH. 


645 


activity  of  growth  of  these  tumors  are  the  periods  when  the  generative 
organs  exhibit  the  greatest  activity.  The  periodical  stimulus  the  uterus 
undergoes  at  the  epochs  of  menstruation  is  shared  by  the  tumors  lodged 
within  its  walls.  The  rapid  enlargement  of  the  uterus  during  preg- 
nancy is  often  attended  by  a  commensurate  growth  of  the  tumors. 


Subperitoneal  fibroid  tumor  of  uterus.    (Half-size,  London  Hospital.) 
The  tumor  is  only  attached  by  a  thin  pedicle  to  the  fundus  uteri. 


But,  although  it  may  be  laid  down  as  a  general  rule,  that  fibroid 
tumors  do  not  continue  to  grow  after  the  termination  of  the  normal 
period  of  menstruation,  it  must  be  admitted  that  exceptions  occur.  I 
have  even  observed  that  the  constitutional  ferment  which  frequently 
attends  this  critical  period  of  life  seems  to  determine  in  the  temporary 
exacerbation  of  any  form  of  uterine  disease  existing  at  the  time.  The 
organic  force  which  had  hitherto  been  exerted  in  healthy  physiological 
work,  is  now  diverted  into  a  morbid  channel.  In  this  way  these  tumors 
not  infrequently  acquire  an  enormous  size,  equalling  or  even  exceeding 
that  of  the  gravid  uterus  at  terra. 

Both  the  subperitoneal  and  the  submucous  tumors  seem  to  be  con- 
stantly pressing  towards  expulsion.  The  first  step  in  this  eifort  is  seen 
in  bulging  or  projeetion  on  the  surface ;  the  second  is  seen  in  peduncu- 
lation,  when  they  are  called  polypi ;  the  third  is  actual  detachment  from 
the  uterus.  The  process  of  extrusion,  a  very  important  point  in  the 
clinical  history  of  these  growths,  deserves  attention.  It  may  be  likened 
generally  to  labor.  The  tumor  is  a  parasitic  growth  which,  drawing 
its  means  of  nutrition  from  the  uterine  wall,  and  stimulating  the  struc- 
ture in  which  it  grows  to  increased  development,  may  be  said  to  pro- 
duce in  the  uterus  a  state  analogous  to  pregnancy.  The  uterus  enlarges, 
its  muscular  element  increases,  and  consequently  its  contractile  property 
is  called  into  play.  The  uterus  thus  developed  tries  to  get  rid  of  its 
parasite.  Contractions  of  its  muscular  coat  act  upon  the  tumor  and 
drive  it  towards  the  nearest  surface,  that  is,  the  tumor  is  made  to  pro- 


646 


riBEOID     TUMOR     OF    THE     UTERUS. 


ject  at  that  part  where  the  investhig  wall  is  thinnest.  One  of  the  con- 
ditions favoring  this  process  is  the  difference  in  solidity  between  the 
tumor  and  the  uterine  wall.  The  texture  of  the  tumor  is  usually  more 
dense  and  compact,  and  is  consequently  less  capable  of  contraction. 
It  cannot  follow  or  partake  in  the  uniform  contraction  of  the  organ  ; 


Fig.  142. 


Fibroid  tumor  of  the  uterus.     (Two-thirds  uat.  size,  St.  Thomas's  Hospital.) 

Showing  encapsulation  in  the  proper  uterine  tissue,  and  attendant  formation  of  cystic  polypi  in  the 

cervix.    The  tumor  starts  from  its  capsule  on  section  being  made. 


as  an  unyielding  body,  preserving  to  a  great  extent  its  original  dimen- 
sions, it  must  be  driven  towards  one  or  other  surface  of  the  uterus  as 
this  diminishes  in  size.  This  liability  to  extrusion  is  the  more  especial 
characteristic  of  the  dense  fibroid  encapsuled  tumors.  Those  tumors 
whose  texture  more  nearly  resembles  that  of  tlie  uterine  wall,  which 
are  continuous  with  this  wall,  show  less  of  this  tendency  towards 
extrusion. 

The  expulsive  action  of  the  uterus  is  strikingly  manifested  in  those 
cases  in  which  the  organ  inverts  itself  in  the  eifort  to  cast  out  a  tumor. 
Cases  of  this  kind  are  described  in  the  chapter  on  "Inversion."  They 
extend  the  similitude  to  labor. 

In  St.  George's  Museum  is  a  specimen  (xiv,  21)  showing  a  fibroid  in 
course  of  spontaneous  elimination.  The  tumor  is  nearly  detached  as 
though  a  ligature  had  been  applied. 

The  attempt  of  the  uterus  to  rid  itself  of  its  guest  by  contraction 
suggests  a  course  of  treatment  which  is  sometimes  followed  bv  success. 
Acting  as  if  the  object  were  to  expel  a  foetus,  ergot,  strychnine,  quinine, 


MODE    OF     EXPULSION. 


647 


galvanism  have  been  employed  to  stimulate  the  expulsive  power  of  the 
uterus.  Sometimes,  aided  in  this  way  or  not,  the  tumor  is  actually 
detached,  and  cast  out  from  the  body.  Many  cases  of  this  method  of 
spontaneous  cure  are  known.  There  appear  to  be  two  ways  in  which 
it  is  carried  out:  1.  The  thin  layer  of  proper  uterine  tissue  which 
forms  the  shell  of  the  tumor  may  become  inflamed  and  give  way ;  the 
tumor  itself  softening,  may  be  broken  up  in  such  a  manner  that  the 
fragments,  not  perfectly  separated  from  each  other,  but  preserving  a 
slight  connection,  may  be  driven  down  into  the  uterine  cavity ;  or  the 

Fig.  143. 


Uterus  with  two  large  fibroid  tumors.    (Half-size,  St.  George's,  xiv.  10.) 

One  projects  into  the  uterus,  filling  its  cavity ;  it  adheres  to  the  inner  surface  of  the  uterus.    The 

other  tumor  is  at  the  back  towards  the  peritoneal  surface,  not  seen  in  this  view. 


tumor  may  come  away  entire,  being,  as  it  were,  enucleated  by  the 
uterine  action.  This  is  especially  likely  to  occur  after  labor.  2.  The 
other  way  is  by  gradual  pedunculation  as  explained.  When  the  stalk 
is  much  thinned,  the  tumor  breaks  away  by  a  slight  force  like  an 
etiolated  leaf  or  ripe  fruit. 

The  extrusion  of  fibroid  tumors  following  labor  is  often  attended  by 
great  danger.  The  tissue  of  the  tumor,  either  through  having  suffered 
violence  from  compression  or  not,  is  very  apt  to  be  affected  by  a  low 
necrotic  form  of  inflammation  which  may  give  rise  to  metritis  and 
pyaemia.  And  even  when  a  tumor  is  expelled  independently  of  labor, 
the  process  is  not  always  carried  out  harmlessly.  Thus,  Cruveilhier 
relates  a  case  of  a  young  woman  who  had  suffered  during  four  months 
from  uterine  hemorrhage,  followed  by  a  discharge  horribly  fetid.  At 
the  end  of  this  time  she  expelled  some  small  masses,  recognized  to  be 
fibrous  tumors.  The  patient,  whose  health  was  undermined  by  hectic 
fever,  and  who  presented  all  the  marks  of  cancerous  cachexia,  recovered, 
contrary  to  all  expectation,  after  the.  expulsion. 

In  St.  George's  Museum  is  a  specimen  (xiv,  20)  "  taken  from  the 


648  FIBROID    TUMOR    OF    THE     UTERUS. 

body  of  a  lady  who,  on  first  consulting  Mr.  Stone,  ])resented  a  tumor 
projecting  from  the  uterus,  and  much  resembling  a  polypus  in  the 
process  of  coming  down.  Severe  pain  came  on,  and  the  tumor  began 
to  project  more,  but  never  presented  any  neck.  She  sank  exhausted 
by  the  discharge." 

Sometimes  the  process  simulates  abortion  so  closely  as  to  be  mistaken 
for  this  event.  This  happened  in  the  case  of  the  wife  of  a  medical 
friend.  After  profuse  hemorrhages  and  expulsive  pains,  a  substance 
of  the  size  and  shape  of  a  small  egg  was  passed.  Both  she  and  her 
husband  believed  she  had  aborted.  But  on  making  a  section  of  the 
mass,  I  found  it  was  a  fibroid  tumor.  It  is  needless  to  say  that  such 
a  series  of  events  occurring  in  a  single  woman  would  almost  infallibly 
give  rise  to  imputation  against  her  chastity.  The  history  enforces  the 
rule  to  submit  every  substance  passed  from  the  uterus  to  careful 
examination. 

The  subperitoneal  tumors  may  also  become  pedunculated,  being  the 
exact  counterparts  of  uterine  poly}>i.  In  proportion  as  the  peduncle 
elongates,  becoming  more  remote  from  uterine  influence,  they  become 
less  and  less  dangerous.  I  have  known  them  to  acquire  a  peduncle  so 
long  that  the  tumor  could  be  grasped  in  the  hand  through  the  abdomi- 
nal wall,  and  be  moved  freely  about,  only  restrained  by  its  mooring  to 
the  body  of  the  uterus.  When  in  this  condition,  the  subject  may  go 
through  pregnancy  and  labor  quite  unaffected.  And,  like  the  uterine 
polypus,  the  subperitoneal  tumor  may  be  actually  cast  oflp.  It  then 
sinks  down  into  the  lower  part  of  the  abdomen,  where  it  may  cause 
peritonitis  or  mechanical  distress ;  or,  its  presence  may  give  rise  to  no 
inconvenience. 

This  tendency  tp  casting-off  by  the  peritoneal  sui^face  is  well  illus- 
trated in  Figs.  141,  144. 

Professor  Turner  (Edin.  Med.  Journ.,  1861),  who  has  discussed  this 
subject  with  illustrative  examples,  says  : 

"  Should  a  subperitoneal  tumor  be  attacked  by  inflammation  of  its 
peritoneal  investment,  and  contract  adhesions  to  surrounding  parts,  it 
is  thus  placed  in  a  position  favorable  to  become  separated  from  the 
uterus.  This  would  be  especially  liable  to  occur  if  it  became  connected 
to  a  viscus,  such  as  the  bladder  or  rectum,  which  is  constantly  under- 
going changes  both  in  size  and  position.  The  alternate  dilatations  and 
contractions  of  these  viscera  would  necessarily  exercise  a  considerable 
traction  upon  the  tumor,  which  w^ould  tend  to  produce  elongation  of 
the  pedicle;  and  ultimately,  should  the  case  be  sufficiently  long  in  ope- 
ration, complete  detachment  from  the  uterus.  Even  if  the  tumor  were 
to  attach  itself  to  a  fixed  part,  as  the  ]->ubes,  or  other  portion  of  the 
pelvic  wall,  and  the  woman  subsequently  become  pregnant,  the  grow- 
ing uterus,  gradually  rising  into  the  abdomen,  might  exercise  such  an 
amount  of  traction  upon  the  pedicle  as  to  attenuate  it  even  to  complete 
separation.  The  entanglement  of  the  tumor  between  the  coils  of  small 
intestine  which  so  frequently  hang  down  into  the  pelvic  cavity,  even 
although  no  distinct  attachments  took  place  between  them,  would, 
during  the  peristaltic  movements  of  the  gut,  exercise  a  certain  degree  of 
dragging  upon  it,  esjDecially  if  at  the  same  time  its  pedicle  became 


CASTING-OUT. 


649 


twisted.  In  those  cases  in  which  the  tumors  attain  great  size,  or  great 
density,  through  calcareous  degeneration,  even  without  becoming  con- 
nected to  adjacent  parts,  their  own  weight  might  probably  assist  in 
producing  attenuation  of  the  pedicle ;  but  in  estimating  this  as  a  cause 


Fibrous  tumors  of  the  uterus.    (Half-size,  St.  George's,  xiv,  9.) 
Some  are  in  the  walls  of  the  uterus  ;  others  between  the  peritoneal  coat  and  outer  surface ;  one  im- 
mediately beneath  the  mucous  membrane  projecting  into  the  cavity  of  the  uterus. 


productive  of  separation,  we  must  always  bear  in  mind  the  constant 
and  reciprocal  pressure  exercised  upon  each  other  by  the  walls  and  con- 
tents of  the  abdominal  cavity." 

The  frequent  occurrence  of  tumors,  which,  in  many  ])athological 
and  clinical  points  are  very  distinct  from  the  ordinary  fibroids,  has  not 
been  sufficiently  recognized.  Yet,  nothing  is  more  important  than  this 
recognition.  They  cannot  always  be  treated  like  fibroids ;  and  what  is 
more  important,  they  cannot  always  be  distinguished  before  operating. 
These  tumors  are  not  so  often  multiple  as  the  hard  fibroid ;  they  almost 
invariably  affect  the  body  of  the  uterus ;  they  attain  a  large  size ;  they 
are  softer,  looser,  more  like  muscle,  have  often  interspaces  filled  with 
serum  ;  they  are  more  disposed  to  become  "  fibro-cystic."  They  are 
not  so  often  encapsuled.  They  are  much  less  disposed  to  calcareous 
degeneration.  They  are  more  liable  to  become  oedematous.  They  are 
more  vascular,  and,  therefore,  more  prone,  under  surgical  interference 
or  other  violence,  to  become  inflamed,  to  undergo  necrosis,  to  give  ori- 


650 


FIBRO-CYSTIC    TUMOR. 


gin  to  septicaemia  and  peritonitis.  They  are  less  prone  to  become 
polypoid,  or  to  be  eliminated.  They  frequently  give  rise  to  profuse 
metrorrhagia.  Fig.  145,  from  a  specimen  in  St.  Thomas's  Museum, 
seems  to  be  an  example  of  this  kind.  It  represents  a  "  uterus  with  a 
large  tumor  developed  in  its  anterior  wall.  The  cavity  of  the  uterus 
is  much  enlarged,  being  almost  equal  to  the  long  diameter  of  the  tumor, 
nearly  seven  inches.  The  posterior  wall  is  |  in.  thick.  The  subject, 
set.  45,  had  long  been  subject  to  profuse  uterine  hemorrhage." 

Red,  fleshy,  loose-textured,  they  contrast  remarkably  with  the  white 
dense,  "subcartilaginous"  appearance  of  the  common  hard  "fibroid." 
The  distinction  was  recognized  by  Cruveilhier  (see  p.  641)  and  is  in- 
sisted upon  by  Rigby. 

The  form  of  uterine  tumor  which,  next  to  the  common  fibroid,  has 
attracted  the  most  attention  is,  the  Jibro-cystic.    This  is  the  form  which 


Fig.  145. 


Fibroid  or  muscular  tumor  of  uterus,  causing  great  enlargement  of  the  uterus  and  uterine  cavity. 
(Three-eightlis  nat.  size,  St.  Tliomas'.s,  0.  G-,  29.) 


has  so  often  been  mistaken  for  ovarian  tumor,  even  inducing  the  sur- 
geon to  jjerform  gastrotomy.  (See  page  312.)  They  seem  to  be  gen- 
erally more  fleshy,  of  looser  texture  than  the  common  fibroid,  more 
continuous  with  the  ])roper  uterine  tissue,  more  vascular,  and  often 
grow  to  a  very  large  size.     Cysts  sometimes  form  in  the  substance  of 


EECURRENT    FIBROID.  651 

fibroids  through  a  localized  inflammatory  process,  so  that  pus  or  serum 
collecting  forms  a  cavity ;  or  an  effusion  of  blood  into  the  substance 
may  in  like  manner  form  a  cavity.  But  in  some  examples,  there  are 
many  spaces  or  cysts  of  various  sizes,  whose  origin  cannot  be  accounted 
for  in  these  ways.  "  The  formation  of  cysts,"  says  Paget,  "  is  not  rare 
in  fibrous  tumors,  especially  in  such  as  are  more  than  usually  loose- 
textured.  It  may  be  due  to  a  local  softening  and  liquefaction  of  part 
of  the  tumor,  with  eifusion  of  fluid  in  the  affected  part,  or  to  an  accu- 
mulation of  fluid  in  the  interspaces  of  the  intersecting  bands;  and  these 
are  the  probable  modes  of  formation  of  the  roughly  bounded  cavities 
that  may  be  found  in  uterine  tumors.  But  in  other  cases,  and  especi- 
ally in  those  in  which  the  cysts  are  of  a  smaller  size,  and  have  smooth 
and  polished  internal  surfaces,  it  is  more  probable  that  their  produc- 
tion depends  on  a  process  of  cyst-formation  corresponding  with  that 
traced  in  the  cystic  disease  of  the  breast  and  other  organs." 

There  is  a  form  of  tumor,  distinguished  by  the  name  of  "i-ecurrent 
fibroid,"  which  affects  the  uterus.  It  presents,  especially  in  this  char- 
acter of  recurrence,  affinities  with  malignant  disease.  Probably  some 
of  the  cases  reported  were  of  the  nature  of  "  sarcoma." 

The  following  history  illustrates  some  of  the  features  of  this  growth: 

Mr.  Hutchinson  presented  to  the  Path.  Soc.  (Trans.,  vol.  viii)  a 
uterus,  the  seat  of  recurrent  fibroid.  A  single  woman,  aged  thirty- 
nine,  had  repeated  floodings.  The  uterus  M-as  enlarged,  os  and  cervix 
normal.  The  uterus  enlarged  rapidly ;  later  a  lobulated  polypoid 
mass  occupied  the  vagina  connected  with  an  intra-uterine  growth. 
The  discharge  was  very  offensive;  the  patient's  aspect  resembled  that 
of  malignant  disease.  A  portion  of  the  mass  was  removed  by  the 
hand.  The  patient's  state  was  very  critical  for  a  fortnight  afterwards, 
masses  of  slough  coming  away.  Then  she  recovered,  and  the  uterus 
scarcely  exceeded  its  normal  size.  But  after  some  months  of  apparent 
good  health  flooding  recurred,  and  the  uterus  was  again  found  very 
large.  Another  attempt  at  enucleation  was  made  by  the  hand.  Again 
she  recovered,  the  uterus  returning  to  its  ordinary  size.  Two  or  three 
months  later,  the  floodings  returned,  and  a  large  growth  was  found  in 
the  uterus.     It  was  removed  by  ligature,  but  she  died  in  a  fortnigiit. 

Every  organ  in  the  body  was  found  healthy  except  the  uterus  and 
vagina.  The  uterus  on  section  was  found  to  contain  a  white  soft 
groM'th  attached  by  a  very  broad  basis  to  the  whole  of  the  fundus  and 
posterior  surface.     The  mucous  lining  of  the  cervix  was  healthy. 

The  tumor  grew  far  too  rapidly  for  a  fibrous  tumor,  was  too  soft, 
and  too  lobulated.  Fibrous  tumors,  too,  do  not  reproduce  themselves. 
There  were  no  other  deposits  in  any  organ  of  the  body,  although  the 
disease  had  existed  three  years.  Its  history  is  like  that  of  recurrent 
fibroids  elsewhere.  Bristowe,  who  reported  on  the  tumor,  confirms 
the  opinion  of  Hutchinson.  It  did  not  present  the  characters  of  any 
of  the  forms  of  cancer  usually  met  with;  it  was  certainly  not  fibrous; 
there  was  no  cancer-juice.  The  tumors  were  composed  of  the  char- 
acteristic oat-shaped  cells  freely  mingled  with  others  of  a  flattened 
fibroid  form,  each  containing  a  single  nucleus,  having  within  it  several 
clearly  defined  nucleoli. 


652 


ERECTILE    TUMOR. 


Mr.  Callender  describes  (Pathol.  Trans.,  vol.  ix)  a  case  of  recurrent 
fibroid  tumor  of  the  uterus,  with  growths  of  a  similar  character  in  the 
pericardium,  the  lungs,  and  in  the  body  of  the  sixth  cervical  vertebra. 
Partly  by  rej^eated  operations,  partly  by  sloughing  of  portions  of  the 
growth,  considerable  fragments  were  from  time  to  time  removed.  The 
fragments  removed  presented  the  ordinary  characters  of  recurrent 
fibroid  tumor.     Profuse  hemorrhages  occurred,  portions  of  the  tumor 


Erectile  tumor  of  the  uterus  (malignant  ?).     (Half-size.     Carswell.) 


being  discharged.  This  was  her  history  for  several  years.  The  uterus 
at  last  increased  greatly  in  size,  being  felt  above  the  umbilicus,  and  a 
lobulated  soft  growth  occupied  the  vagina,  and  was  continuous  with 
that  which  filled  the  interior  of  the  womb.  She  died  exhausted.  The 
impression  was  that  the  operations  did  not  retard  the  growth,  the  re- 
productive power  was  so  great.  The  uterus  contained  a  tumor  con- 
tinuous wath  one  in  the  iliac  fossa.  Passing  up  from  the  pelvis,  the 
lumbar  glands  were  found  infiltrated  with  the  fibroid  material. 

Carswell  figures  ("Pathol.  Anatomy")  an  erectile  tumor  of  the 
uterus.  Fig.  146  "represents  an  erectile  tumor  of  the  uterus  which 
gives  rise  to  frequent  and  extensive  hemorrhage,  a.  Vagina;  h.  Cavity 
of  uterus  greatly  enlarged ;  c.  A  fibrous  tumor  lodged  in  the  substance 
of  the  uterus,  and  projecting  inwards,  covered  by  the  mucous  membrane 
d;  e.  The  erectile  tumor  rising  above  the  surface  of  the  uterus,  covered 
by  a  smooth,  glossy  membrane,  and  traversed  by  a  multitude  of  ves- 
sels, from  which  the  hemorrhage  proceeded." 

In  the  same  work  Carswell  figures  a  specimen  of  atrophy  of  the 
uterus  and  ovaries  from  ossification  of  the  arteries.     Projecting  in  the 


FIBROID     TUMORS.  653 

cavity  of  the  uterus  is  "a  tumor  composed  of  dilated  veins  and  cellulo- 
fibrous  tissue." 

The  Development  and  Decay  of  Fibroid  Tumors. 

1.  During  the  Period  of  Groicth. — A  fibroid  tumor  being  like  in  con- 
stitution to  the  uterine  muscular  wall,  growing  in  it  and  depending 
upon  it  for  its  existence  and  nutrition,  may  be  expected  to  follow  closely 
the  conditions  of  its  parent  organ.  Accordingly,  it  grows  during  preg- 
nancy, and  undergoes  retrogression  or  involution  when  pregnancy  is 
over ;  and  sometimes  involution  being  thus  started  passes  into  atrophy, 
and  the  tumor  disappears  altogether,  as  in  cases  narrated  by  Dr.  Sedg- 
wdck,^  Scanzoni,  and  others.  Thus  pregnancy  may,  in  very  exceptional 
cases,  it  is  true,  cure  fibroid  tumors.  This  process  of  complete  absorp- 
tion or  atrophy  has  been  questioned.  It  has  been  objected  that  the 
tumor  was  simply  cast  off  unobserved.  But  since  the  uterus  itself  may 
vanish  through  atrophy,  so,  a  fortiori,  may  a  fibroid  tumor. 

They  may  soften  and  become  fluctuating,  oedematous.  Cavities  or 
cysts  may  form  in  them  containing  pus,  blood,  or  serum.  When  these 
cysts  are  large,  and  the  tumor  rises  into  the  abdomen,  the  tumor  is 
called  fibro-cystic,  and  may  simulate  ovarian  disease.  I  incline,  how- 
ever, to  think  that  it  is  not  so  often  the  pure  fibroid  which  is  liable  to 
this  state,  but  the  more  fleshy  tumor,  wdiose  texture  is  looser  and  more 
continuous  with  the  proper  structure  of  the  uterus.  The  fibroid  may 
undergo  inflammation,  suppuration,  and  gangrene. 

It  has  been  supposed  that  fibroid  polypi  are  liable  to  become  con- 
verted into  scirrhus  or  cancer.  It  can  hardly  be  admitted  that  the 
abnormal  muscular  growth  of  which  they  are  composed  is  more  liable 
to  such  a  change  than  is  the  normal  muscular  structure  of  the  womb. 
A  muscular  fibre  cannot  be  changed  into  cancer.  It  may,  however, 
give  place  to  it.  It  is  quite  possible  that  the  cancer  element  may  be 
developed  in  the  substance  of  a  uterine  tumor,  as  it  may  be  in  the 
proper  substance  of  the  uterus  ;  and  that  the  activity  of  the  new  growth 
may  cause  the  atrophy  of  the  old,  and  the  gradual  substitution,  not 
conversion,  of  a  cancerous  tumor  for  a  benignant  polypus. 

Or  the  normal  structure  of  the  uterus  or  vagina  being  first  the  seat 
of  cancer,  the  disease  may  spread  and  invade  the  fibrous  tumor.  Of 
this  I  have  seen  examples.  In  one  case  I  removed  a  large  fibroid  or 
muscular  tumor  which  showed  no  trace  of  malignant  disease.  The 
patient  got  apparently  well ;  but  two  years  later  it  was  found  that 
malignant  disease  had  been  developed  in  the  uterus. 

Tli€  following  history  by  Drs.  Benporath  and  Liebman  illustrates 
this  question : 

A  woman,  aged  forty-eight,  had  suffered  from  metrorrhagia,  had  had 
in  early  life  several  abortions,  and  in  the  latter  years  had  never  con- 
ceived. A  tumor  became  manifest  in  the  abdomen.  After  death  a 
careful  examination  was  made.  There  was  a  fibroid  near  the  right 
Fallopian  tube;    another  almost  encircling  the  uterine  cavity   lower 

1  St.  Thomas's  Hospital  Reports. 


654  FIBROID    TUMOES. 

down ;  carcinoma  of  the  upper  part  of  the  vagina.  It  resulted  that 
the  lower  segment  of  the  uterus  was  invaded  by  the  progress  of  the 
vaginal  cancer,  and  with  it  the  fibroid  tumors  contained  in  its  walls. 
The  lower  parts  of  the  tumor  were  most  affected;  tiie  upper  parts,  those 
most  remote  from  the  original  seat  of  the  cancer,  were  free.  The  case 
may  be  summed  up  as  follows :  Uterine  fibroids  possess  no  immunity 
from  cancerous  degeneration;  but  they  are  scarcely  more  prone  to  it 
than  the  proper  uterine  tissue. 

2.  During  the  Period  of  Retrogression. — When  the  normal  ovarian 
stimulus  to  uterine  growth  ceases  at  the  climacteric,  there  is  a  tendency 
in  fibroid  tumors  to  undergo  the  like  retrogression  or  senile  involution 
or  atrophy  which  seizes  upon  the  uterus.  They  sometimes  diminish 
in  bulk.  They  generally  tend  to  become  inert,  oifending  only  by  their 
bulk  and  mechanical  interference  with  surrouudinw;  organs.  But  not 
seldom,  uterine  fibroid  growing  prolongs  the  period  of  uterine  growth. 
Hence  hemorrhages  continue  recurring  with  more  or  less  periodicity 
until  the  age  of  fifty,  or  even  beyond. 

Lancereaux  (Atlas  d'Anat.  Pathol.,  1871)  says  the  fatty  transforma- 
tion of  fibroids  is  the  most  common. 

In  muscular  tumors  and  polypi  of  long  standing,  the  vessels  often 
become  very  scanty,  or  disappear.  Their  entire  structure  sometimes 
undergoes  an  earthy  or  bony  degeneration.  In  this  condition,  the  hemor- 
rhages which  had  attended  the  earlier  stages  of  their  growth  often  cease. 
They  seem  to  be  removed  by  this  change  from  the  sphere  of  organic 
activity,  and  excite  little  or  no  irritation  in  the  organs  with  which  they 
are  connected. 

I  examined  the  body  of  a  lady  who  had  died  suddenly  from  heart- 
disease,  at  the  age  of  about  sixty.  Thirty  years  previously  she  had 
suffered  from  repeated  uterine  hemorrhages,  when  she  was  thought  by 
her  physicians  in  Holland  to  be  laboring  under  scirrhus  uteri.  I 
found  one  of  the  ovaries  converted  into  bone ;  the  other  partly  into 
cartilage  and  partly  bone.  In  the  place  of  the  uterus  was  an  immense 
firm,  fibrous  tumor,  partly  converted  into  an  osseous  substance.  This 
tumor  had  undoubtedly  been  the  cause  of  the  floodings  she  had  expe- 
rienced in  early  life. 

This  stony  or  bony  conversion  is  not  very  uncommon.  It  especially 
affects  the  hard  fibroid  tumors.  There  are  some  excellent  examples  in 
the  Museum  of  St.  Thomas's  Hospital,  and  in  most  of  the  other  hospital 
museums  of  London.  Fig.  147  is  from  a  specimen  in  St.  Thomas's. 
Baillie  describes  "  a  bony  mass  in  the  cavity  of  the  uterus,"  and  sus- 
pects it  is  the  result  of  the  conversion  of  a  hard  tubercle  (fibroid). 

The  process  of  calcification  may  be  manifested  in  two  forms  :  one 
is  peripheral  incrustation,  by  which  the  tumor  acquires  a  shell  of  cal- 
careous matter ;  the  other  is,  calcareous  infiltration,  the  substance  of 
the  tumor  being  pervaded  with  the  earthy  material.  This  is  found  to 
be  phosphate  of  lime  and  carbonate  of  lime. 

In  Bartholomew's  Museum  is  a  specimen  (No.  32.50)  which  affords 
clinical  illustration  of  one  feature  in  the  history  of  calcification,  "  It 
is  a  large  lobed  fibrous  tumor,  spontaneously  expelled  from  the  uterus. 
The  texture  is  softened  and  soaked  with  fluid,  as  if  through  partial  de- 


EFFECTS. 


655 


composition.  On  its  surface  are  numerous  thin  plates  of  bone-like 
substance,  which  seem  to  have  been  nearly  separate  while  it  decom- 
posed. The  plates  are  simply  calcification  of  the  librous  tissue.  Pa- 
tient, aged  forty -six,  had  observed  the  tumor  for  twenty  years ;  during 
that  time  had   borne  many  children.     For  many  weeks  prior  to  dis- 


FlCr.  147. 


/; 


Ossified  or  cretificd  fibroid  tumor  of  uterus.    (Half-size,  St.  Thomas's,  G.  G.  40'.) 


charge  of  tumor,  which  was  expelled  with  pains  like  those  of  labor, 
flakes  of  bones  passed  away.  Her  recovery  was  comjilete."  (Cata- 
logue.) 

This  source  of  bone  mu.st  be  borne  in  mind.  By  examination,  the 
masses  discharged  may  be  distinguished  from  the  foetal  bones  of  extra- 
uterine gestations. 

Effects  of  Fibroids  upon  the  Uterus,  surrounding  Organs,  and  the 
System  generally. — Let  us  first  examine  the  connection  of  fibroid  tumors 
with  the  uterus.  The  hard  fibroids  commonly  have  no  continuity  of 
tissue  with  the  uterine  substance.  They  are  surrounded  by  a  layer  of 
loose  connective  tissue,  and  then  by  developed  muscular  tissue  of  the 
uterus  disposed  in  a  stratified  manner.  The  tumor  is  therefore  encaj)- 
suled.  It  is  upon  this  disposition  that  the  process  of  enucleation, 
spontaneous  or  surgical,  depends.  In  some  cases,  however,  it  is  pre- 
sumed as  the  consequence  of  inflammation,  the  tumor  contracts  adhe- 


656  FIBROID    TUMORS. 

sions  with  the  uterine  wall.  This  may  occur  whilst  the  tumor  is  still 
intramural,  attachments  forming  with  the  muscular  wall  in  which  it 
is  imbedded.  But  when  the  tumor  has  become  polypoid,  and  projects 
into  the  uterine  cavity,  adhesions  become  more  frequent.  Thus  a  tu- 
mor may  be  more  or  less  completely  adherent  to  the  mucous  membrane 
of  the  uterus  or  vagina.  There  is  a  fine  example  of  vaginal  adhesion 
in  St.  George's  Museum  (xiv,  43).  The  uterine  adhesion  is  not  un- 
common ;  it  may  usually  be  broken  down  by  the  finger. 

An  important  point  in  the  constitution  of  fibroid  tumors  of  the 
uterus  is  their  vascularity.  Cruveilheir  observed  that  "  it  is  in  these 
bodies  that  the  vascular  system  of  fibrous  bodies  in  general  can  best 
be  studied.  A  considerable  vascular  network  envelops  them ;  this  is 
entirely  venous  ;  it  communicates  largely  with  the  veins  of  the  uterus, 
which  have  acquired  a  calibre  proportioned  to  that  of  the  volume  of 
the  fibrous  bodies,  and  to  the  development  of  the  uterus.  On  the 
other  hand  this  venous  network  receives  all  the  veins  which  arise  in 
the  substance  of  these  bodies.  No  uterine  artery  has  appeared  to  me  to 
penetrate  the  fibrous  bodies,  whose  circulation  is  reduced  to  its  most  sim- 
ple expression  ;  no  lymphatic  vessel  has  been  demonstrated ;  no  uterine 
nerve  has  been  traced  into  them.  Hence  the  absolute  insensibility  of 
these  bodies." 

When  a  tumor  is  submucous  or  polypoid,  its  mucous  investment  ex- 
hibits evidence  of  greater  vascularity  than  is  proper  to  the  healthy 
membrane.  When  a  ligature  is  put  on  such  a  tumor,  the  vessels  being 
strangled  become  gorged,  dark-red,  and  easily  bleed.  When  seized  by 
vulselkira,  ecchymosis  is  produced  from  the  rupture  of  small  vessels  ; 
but  this  appearance  is  chiefly  seen  in  the  capsule  of  the  tumor ;  deeper 
in  the  substance  the  tissue  even  under  section  shows  little  sign  of 
bloodvessels  being  divided.  There  is,  however,  an  injected  specimen 
in  St.  George's  Museum  (xiv,  65)  whicli  shows  the  injection  throughout 
the  substance.  It  appears  to  be  a  true  fibroid.  In  Bartholomew's  is 
a  specimen  (32.12)  showing  "several  tumors  in  the  uterine  wall.  The 
vessels  of  the  uterus  have  been  injected,  and  the  injection  has  entered 
the  tumors."  Examination  of  this  specimen  will,  however,  show  that 
this  is  true  chiefly  of  one  large  tumor  near  the  inner  surface  of  the 
uterus,  and  of  looser  texture ;  and  that  this  tumor  is  less  vascular  than 
the  uterine  wall  itself,  whilst  two  smaller  tumors,  subperitoneal,  are 
scarcely  injected  at  all.  In  another  specimen  in  the  same  museum 
(32.6),  "  a  section  of  a  uterus,  with  a  firm  fibrous  tumor  imbedded 
in  the  middle  of  its  anterior  wall,  the  vessels  are  minutely  injected  ; 
but  none  of  the  injection  appears  in  the  morbid  growth."  This  re- 
mains white,  in  remarkable  contrast  with  the  vascular  uterus. 

This  comparative  absence  of  vessels,  and  the  consequent  low  vitality, 
accounts  for  the  impunity  with  which  these  tumors  can  be  cut  or  lacer- 
ated during  surgical  operations.  The  venous  character  of  the  blood- 
vessels on  their  surface  explains  the  free  hemorrhages  occurring  whilst 
they  retain  their  relations,  and  the  speedy  cessation  of  the  bleeding 
when  the  tumors  are  removed. 

Connected  with  the  vascularity  is  the  source  of  the  hemorrha,ge  which 
is  so  common   a  consequence  of  fibroid  tumors  and  polypi.     It  has 


EFFECTS.  657 

been  contended  that  the  blood  flows  principally,  if  not  exclusively, 
from  the  surface  of  the  polypus.  Lisfrauc  especially  strenuously  ad- 
vocated this  view.  It  has  been  urged  in  support,  that  the  hemorrhage 
is  observed  to  be  immediately  arrested  upon  the  removal  of  the  tumor, 
and  even  in  many  cases  upon  the  application  of  a  ligature.  It  has 
been  pointed  out  that  the  pedicles  of  large  polypi  frequently  carry 
bloodvessels  of  considerable  size,  that  the  investing  membrane  is 
highly  vascular,  and  that  it  has  been  seen  to  pour  out  blood  upon 
being  injured.  On  the  other  hand  it  has  been  urged  that  the  real 
source  of  the  blood  is  the  mucous  surface  of  the  uterus.  Whilst  the 
particular  facts  urged  in  support  of  the  view  that  the  surface  of  the 
polypus  pours  out  the  blood,  admit  of  a  complete  solution  by  the 
theory  that  it  is  poured  out  by  the  uterus,  there  are  also  special  reasons 
which  support  this  latter  opinion.  It  is  observed  that  profuse  hemor- 
rhage attends  very  small  polypi  as  well  as  those  of  large  size ;  and  it 
is  difficult  to  imagine  how  the  extensive  and  rapid  losses  of  blood 
which  often  occur  can  escape  from  the  surface  of  a  tumor  in  many  in- 
stances not  larger  than  a  small  nut.  Again,  the  hemorrhage  mostly 
assumes  the  form  of  profuse  menstruation;  and  it  will  not  be  con- 
tended that  the  ordinary  menstrual  flow  comes  from  any  other  source 
than  the  uterus.  Metrorrhagia  may  arise  from  any  cause  which  sets  up 
a  preternatural  action.  The  presence  of  a  polypus  is  a  cause  of  in- 
creased afflux  of  blood.  It  is  difficult  then  to  avoid  the  conclusion 
that  the  excess  of  the  ordinary  menstrual  discharge  occurring  when  a 
polypus  is  present  flows  like  the  normal  proportion  from  the  womb. 
When  the  tumor  or  polypus  is  very,  large,  almost  the  entire  mucous 
membrane  of  the  uterus  may  be  protruded  before  it ;  that  is,  there  is 
no  mucous  membrane  but  that  investing  the  tumor.  Why  the  hemor- 
rhage ceases  when  the  tumor  is  removed,  is  exactly  why  it  ceases  after 
the  expulsion  of  the  ovum  in  abortion.  The  developmental  attraction 
of  blood  is  at  an  end. 

It  has  been  observed  that  in  some  cases  the  menstrual  flow  is 
actually  lessened. 

Fibroids  almost  invariably  cause  enlargement,  more  or  less  deformity, 
and  displacement  of  the  uterus.  They  may  produce  every  variety  of 
flexion,  and  even  inversion.  By  attracting  an  undue  supply  of  blood, 
they  often  induce  congestion ;  sometimes  chronic  endometritis  ;  these 
conditions  give  rise  to  hypertrophy  of  the  uterus  generally,  and  to 
glandular  irritation  and  outgrowths  in  the  cervix. 

The  disposition  to  neoplasraata  or  outgrowths  where  fibroid  tumors 
exist,  is  very  great.  Thus  we  frequently  find  not  only  multiple  tumors 
in  the  body  of  the  uterus,  but  tumors  of  various  kinds  in  the  cervix  as 
well.  And  it  is  not  uncommon  to  find  complications  in  the  form  of 
cystic  disease  of  the  ovaries,  and  dilatation  with  obstruction  of  the 
Fallopian  tubes. 

In  St.  Bartholomew's  Museum  is  a  specimen  (No.  32.52)of  a  uterus, 
in  the  side  wail  of  which  is  imbedded  a  large  fibrous  tumor.  The 
tumor  has  bent  the  uterus  laterally,  and  so  encroached  upon  its  cavity, 
that  the  cervical  portion  was  shut  off  from  that  within  its  body.     The 

42 


658  FIBROID    TUMORS. 

cavity  of  the  uterus  is  greatly  dilated ;  its  walls  are  thinned ;  its  mucous 
membrane  was  intensely  vascular,  and  it  was  filled  with  pus. 

Another  specimen  in  the  same  museum  (No.  32.13)  shows  retrograde 
dilatation  of  the  uterus  above  the  seat  of  constriction.  It  exhibits  the 
obliteration  of  that  portion  of  its  cavity  which  is  within  the  cervix. 
The  rest  of  its  cavity  is  dilated.  The  extremities  of  the  Fallopian 
tubes  are  adherent  to  the  ovaries. 

But  in  a  considerable  proportion  of  cases  the  cervical  portion  remains 
free  from  other  than  mechanical  distortion.  A  small  fibroid  in  the 
anterior  wall  may  cause  anteflexion,  one  in  the  posterior  wall  retro- 
flexion. A  larger  tumor  in  the  anterior  wall  may,  however,  push  the 
fundus  over  backwards,  producing  retroflexion,  and  vice  versa.  If 
growing  in  the  sides  of  the  uterus,  or  indeed  elsewhere,  if  they  develop 
unequally  they  destroy  the  symmetry  of  the  organ,  may  distort  it  in 
any  conceivable  manner,  so  that  there  is  nothing  in  nature  more  fan- 
tastic than  the  shapes  which  a  uterus  invaded  by  fibroid  tumors  may 
assume.  The  cervix  itself,  although  generally  free  from  tumor,  may 
be  twisted  and  distorted  in  the  most  extraordinary  manner.  It  is  often 
flattened  out  on  the  deformed  body  of  the  uterus ;  the  course  of  its  canal 
is  made  tortuous,  and  its  calibre  compressed  or  obliterated.  The  os 
uteri  may  be  small  or  large.  Sometimes  it  is  very  difficult  or  impos- 
sible to  pass  a  sound  along  it,  so  devious  and  narrow  is  the  canal. 

The  uterus  impeded  in  its  functions  gives  rise  to  the  following 
symptoms :  dysmenorrhoea,  dyspareunia,  and  sterility.  These  are 
especially  apt  to  occur  when  the  body  of  the  uterus  is  bent  upon  the 
cervix  at  a  right  or  even  an  acute  angle,  constricting  the  os  internum. 
In  the  event  of  pregnancy  occurring,  abortion  is  a  very  probable  issue. 
Such  cases  are  apt  to  lead  to  profuse  flooding.  The  uterine  wall  is 
unable  to  contract  uniformly.  The  course  to  adopt  is — 1,  to  remove 
the  ovum  completely  by  preliminary  dilatation  of  the  cervix,  if  neces- 
sary ;  2,  by  swabbing  the  interior  of  the  uterus  with  persulphate  of  iron. 

Fibroids  may  cause  dragging  and  atrophy.  Thus  Bristowe  and 
Hutchinson  (Path.  Trans.,  vol.  viii)  report  on  a  case  of  absence  of  the 
cavity  of  the  uterus  and  extreme  atrophy.  Two  tumors  existed,  and 
had  become  pedunculated,  and  it  is  evident  that  between  them  the  uterus 
had  been  pulled  out  and  attenuated.  It  is  probable  too  that  in  this  case, 
as  in  others,  the  tumors  were  at  first  surrounded  by  the  substance  of 
the  uterus,  and  that  as  they  became  detached,  they  carried  with  them  as 
a  capsule  a  considerable  portion  of  the  uterine  tissue,  which  has  since 
wholly  disappeared,  and  between  these  two  processes,  co-operating  in 
the  same  direction,  there  can  be  no  difficulty  in  understanding  how  the 
body  of  the  womb  should  have  been  reduced  to  the  remarkable  condi- 
tion in  which  it  was  found.  Fibroids  may  even  cause  axial  twisting 
of  the  uterus,  as  in  a  case  related  by  Dr.  E.  Kiister.^  "An  unmarried 
woman,  aged  thirty-four,  who  had  suffered  from  dysmenorrhoea,  died 
of  diarrhoea.  The  body  of  the  uterus  was  as  large  as  a  man's  head  and 
presented  several  projections  on  its  surface.  Through  the  enlargement 
of  the  body  of  the  uterus,  the  neck  was  enormously  drawn  out  and 

1  Beitrage  zur  Geburtskunde  uiid  Gynakologie,  1870. 


EFFECTS.  659 

twisted.  It  had  undergone  two  and  a  half  turns,  so  that  the  right 
ovary  was  turned  to  the  left  and  forwards,  and  the  anterior  surface  of 
the  uterus  was  turned  backwards.  The  cervical  canal  was  almost 
closed;  its  walls  were  very  thin,  its  length  was  ten  centimetres.  The 
cavity  of  the  uterus  was  filled  with  blood." 

A  submucous  tumor  even  if  not  quite  polypoid,  may  by  pressure 
upon  the  opposite  uterine  Avail  cause  ulceration,  perforation,  and  even 
rupture.  Larcher  relates  the  following  case  (Arch.  Gen.  de  Med.,  1867) : 
"A  woman  was  admitted  into  the  Hotel-Dieu  with  pain  in  the  abdomen. 
After  four  days  profuse  bleeding  set  in.  She  refused  examination. 
Two  days  later  meteorism  and  peritonitis  appeared,  and  she  died.  Sec- 
tion revealed  diffuse  peritonitis  and  adhesion  of  all  the  organs  of  the 
small  pelvis.  A  polypus  was  found  in  the  uterus,  seated  in  the  anterior 
wall  near  the  isthmus.  The  posterior  surface  of  the  cervix  was  ulcer- 
ated, and  at  one  point  torn  through,  communicating  with  the  cavity  of 
the  abdomen." 

I  have  recorded  a  case  (Obstetrical  Transactions)  in  which  a  small 
tumor  in  the  anterior  wall  of  the  uterus  led  to  perforation  into  the 
bladder,  owing  to  the  pressure  caused  by  the  passage  of  the  head  in 
labor. 

The  effects  upon  the  surrounding  organs  are  those  oi  pressure  and  con- 
sequent interference  with  their  functions.  If  the  uterus  enlarged  by 
tumors  be  retained  in  the  pelvic  cavity,  and  grow  to  the  extent  of  com- 
pressing the  surrounding  parts  against  the  unyielding  walls  of  the  pel- 
vis, the  results  will  be  similar  to  those  caused  by  retroversion  of  the 
gravid  womb  or  a  retro-uterine  heematocele.  But  they  come  on  more 
gradually.  The  uterus  in  its  growth  causes  eccentric  pressure.  The 
bladder,  at  first  irritated,  is  frequently  excited  to  void  itself,  then,  per- 
haps, retention  of  urine  follows.  The  rectum  may  exhibit  signs  of 
tenesmus,  and  constipation  is  very  common.  Pain  and  reflex  irritation 
set  up  expulsive  efforts  in  the  uterus  and  abdominal  muscles. 

Complete  obstruction  may  even  be  caused,  and  simulate  most  of  the 
conditions  of  strangulated  hernia.  Dr.  Peter  Eade,  of  Norwich,  com- 
menting (Lancet,  1872)  upon  three  cases  of  the  kind,  suggests  that  such 
cases  might  be  relieved  by  Amussat's  operation,  and  asks  whether  ex- 
ploratory gastrotomy,  with  a  view  to  the  removal  of  the  tumor,  be 
worthy  of  serious  consideration  in  the  case  of  intestinal  obstruction? 
If  the  obstruction  be  connected  with  movable  subperitoneal  tumors, 
as  in  one  of  Dr.  Eade's  cases,  this  proceeding  would  offer  considerable 
hope  of  benefit.  But  where,  as  is  most  frequently  the  case,  the  ob- 
structing tumors  form  part  of  the  uterus,  little  good  can  be  expected 
from  gastrotomy,  unless  the  uterus  itself  be  removed.  But  regarding 
intestinal  obstruction  or  strangulation  from  an  enlarged  surgical  point 
of  view,  it  may  fairly  be  stated  as  a  general  proposition,  that  if  no 
external  hernia  be  found  as  the  presumed  seat  of  obstruction,  search 
should  be  made  for  it  by  gastrotomy.  Cases  of  internal  strangulated 
hernia  have  been  reported  which  justify  this  operation;  and  we  may 
find  constriction  by  fibrinous  adhesions,  which  may  be  divided,  or 
twisting  of  the  bowel,  which  may  be  released,  or,  as  is  not  uncommon 
in  children,  invagination. 


660  FIBROID    TUMORS. 

Pressure  upon  the  sacral  plexus  may  cause  excruciating  pain  in  the 
form  of  sciatica.  This  I  have  seen  several  times.  Dr.  G.  H.  Kidd 
relates  an  interesting  example  (Dublin  Med.  Journ.,  1872).  The  pain 
was  relieved  by  wearing  an  air-pessary  to  lift  up  the  tumor.  The 
tumor  ultimately  completely  disappeared.  Dr.  Kidd  calls  attention  to 
the  important  clinical  fact  that  these  pressure  eifects  are  more  or  less 
intermittent.  He  explains  this  by  remarking  that  the  pressure  is  often 
increased  at  the  menstrual  epochs.  He  noticed  in  one  case  that  sciatica 
was  always  increased  at  these  times.  He  further  observes  that  great 
increase  of  pressure  arises  from  flatulent  distension  of  the  bowels.  He 
has  known  pressure  from  above  so  caused  to  drive  a  tumor  more  firmly 
into  the  pelvis. 

Large  tumors  growing  in  the  abdominal  cavity  may  produce  mechani- 
cal effects  similar  to  those  resulting  from  large  ovarian  tumors.  They 
may,  although  this  seems  rare,  cause  peritonitis  and  ascites,  and  ad- 
hesions resulting  may  lead  to  strangulation  of  the  intestines.  They 
may  be  the  cause  of  laceration  of  the  intestines  by  dragging,  as  under 
the  influence  of  sudden  shock  or  fall.  And  by  mere  bulk,  they  may 
so  impede  the  action  of  the  heart  and  lungs,  as  to  bring  about  gradual 
asphyxia  and  exhaustion. 

Retrograde  disorder  of  the  alimentary  canal  ensues  from  the  rectal 
obstruction.  Flatulence,  various  dyspeptic  phenomena,  blood-contami- 
nation from  absorption  of  the  products  of  decomposition  of  retained 
fecal  matter — a  condition  for  which  I  have  proposed  the  term  "coprse- 
mia" — ensues. 

A  time  arrives  when,  if  the  tumor  is  not  dislodged  from  the  pelvis, 
the  pressure  becomes  so  great  that  the  distress  arising  from  pain  and 
impeded  function  becomes  intolerable;  and  the  obstruction  to  the  local 
circulation  may  be  so  complete,  that  gangrene  of  the  vagina  is  caused. 
The  bladder  becomes  congested,  inflamed,  the  ureters  and  kidneys  dis- 
tended, and  death  may  ensue  from  urinsemia. 

We  may  sum  up  the  dangers  ensuing  upon  the  presence  of  fibroid 
tumors  in  the  uterus  as  follows,  premising  that  in  a  large,  but  unknown 
proportion  of  cases,  no  ill  consequence  occurs :  1.  Hemorrhage.  This 
may  be  fatal.  The  hemorrhage  is  mostly  recurrent,  and,  as  in  other 
cases  of  repeated  hemorrhage,  the  system  accommodates  itself  more  or 
less  to  the  losses,  acquiring  the  power  of  rapidly  regenerating  blood. 
More  often  the  hemorrhages  prove  injurious  by  degrading  nutrition 
generally,  by  inducing  2,  Exhaustion,  under  which  the  patient  is  liable 
to  sink  gradually  or  more  quickly  under  the  immediate  effect  of  some 
secondary  disease,  to  which  the  exhausted  system  is  especially  prone. 
3.  A  not  unfrequent  cause  of  death  is  Peritonitis.  McClintock  says, 
"from  his  own  experience,  the  most  fruitful  source  of  danger  is  peri- 
toneal, or  pelvic  inflammation."  The  fotal  attack  may  be  induced  by 
the  giving  way  of  the  serous  membrane  over  a  fibrous  tumor,  which 
has  undergone  the  process  of  softening ;  or  there  may  be  escape  of  foul 
matter  from  the  tumor  into  the  peritoneum.  Another  mode  in  which 
not  only  peritonitis  may  occur,  but  4,  Metritis  and  lyycemia,  is  from 
partial  decomposition  of  the  tumor.     5.  Pressure  impeding  the  func- 


SYMPTOMS     AND     DIAGNOSIS.  661 

tions  of  the  bladder,  kidneys,  intestines,  stomach,  lungs,  or  heart,  or 
causing  mechanical  lesions  of  these  organs. 

Symptoms  and  Diagnosis. — The  symptoms  are  the  expression  of  those 
features  the  history  of  which  has  been  already  discussed.  They  may 
be  briefly  summed  up  as  follows:  1.  Those  which  take  their  rise  in 
the  uterus  itself.  2.  Those  which  are  the  result  of  interference  of  the 
affected  uterus  on  neighboring  organs.  3.  The  remote  or  constitutional 
symptoms.  4.  The  physical  or  objective  signs.  The  signs  of  the  first 
three  kinds  are  many  of  them  common  to  other  affections  of  the  uterus 
or  of  neighboring  structures.  They  can  hardly  obtain  the  importance 
of  being  diagnostic.  Thus,  pain  and  hemorrhage  referred  to  the  ute- 
rus, attend  many  other  conditions.  The  pain  is  generally  of  spasmodic 
character ;  it  is  more  common  when  the  tumor  projects  into  the  uterine 
cavity,  or  towards  its  external  surface ;  it  is  in  these  cases  the  evidence 
of  contraction  tending  to  cast  out  the  tumor  from  its  walls.  It  is  not 
constant.  Scanzoni  observes  that  the  spasmodic  pain  is  greater  in  the 
case  of  intramural  tumors  than  of  polypi. 

Tiie  hemorrhage  varies  greatly.  Cruveilhier  had  noticed  that  it  was 
less  common  when  the  tumor  was  subperitoneal.  It  is  most  common 
when  it  is  submucous,  and  is  rarely  absent  when  it  is  polypoid.  It 
usually  observes  some  degree  of  periodicity,  that  is,  it  takes  the  form 
of  menorrhagia.  But,  in  not  a  few  cases,  hemorrhage  breaks  out  in 
the  intermenstrual  intervals ;  and  in  some  of  long  standing,  it  becomes 
constant  or  nearly  so,  alternating  at  times  with  a  sanious  serous  oozing 
likened  to  the  green  waters  which  follow  labor. 

Irritation  or  obstruction  of  the  bowel  or  bladder,  dorsal  and  sacral 
pain,  dysmenorrhoea  and  dyspareunia,  with  or  without  hemorrhage, 
are  common  to  retro-uterine  hsematocele,  and  retroversion  of  the 
uterus. 

The  remote  signs,  those  referred  to  the  nervous  system,  and  those 
resulting  from  blood-impairment  and  disordered  nutrition,  are  equally 
observed  in  various  other  pelvic  disorders.  AVe  are  then  compelled  to 
resort  to  physical  exploration  in  order  to  trace  these  symptoms  to  their 
actual  cause.  As  we  have  already  seen  in  Chapter  VI,  pain  and 
hemorrhage  must  be  regarded  as  "  conditions  indicating  the  necessity 
for  examination." 

When  examination  is  made  by  touch  we  become  conscious  that  the 
uterus  is  altered  in  size,  shape,  position,  and  consistence.  We  then,  by 
applying  the  various  means  at  our  disposal,  try  to  assign  these  altera- 
tions to  their  true  cause.  Of  the  cases  which  most  frequently  lead  to 
error  some  are  external  to  the  uterus ;  they  deceive  by  concealing  the 
uterus  from  observation.  The  moment  we  can  detect  the  uterus  and 
can  determine  its  outline,  we  are  at  once  in  a  position  to  exclude 
tumors  in  its  substance.  Such  are  retro-uterine  hsematocele,  perimet- 
ric inflammatory  effusions,  ovarian  tumors,  accumulations  in  the  rectum. 

In  some  cases  the  source  of  error  lies  in  conditions  of  the  uterus  it- 
self. Such  are  retroflexion,  anteflexion,  and  other  deviations  from  the 
natural  shape ;  enlargement  from  hyperplasia,  of  the  uterus  ;  preg- 
nancy ;  malignant  disease  of  the  uterus. 

The  diagnosis  of  fibroid  tumors  flows  in  great  measure  from  the  con- 


662  FIBROID     TUMORS. 

sideration  of  their  natural  history,  and  of  the  effects  they  produce  upon 
neighboring  organs.  It  is,  however,  especially  necessary  to  call  atten- 
tion to  the  signs  brought  out  by  physical  exploration.  The  uterus  is 
almost  necessarily  increased  in  bulk.  This  may  be  determined  by  vag- 
inal touch.  Poising  the  uterus  on  the  tip  of  the  finger  we  feel  the  in- 
creased weight.  By  combining  abdominal  palpation,  we  determine  ac- 
curately the  extent  of  the  enlargement,  measuring  the  organ  between 
the  two  hands.  We  may  often  distinguish  enlargement  due  to  fibroid 
tumor  from  the  enlargement  due  to  hypertrophy  or  subinvolution,  by 
observina;  the  form  of  the  uterus.  In  the  latter  cases  the  enlarg^ement 
is  uniform,  the  organ  remains  smooth  on  the  outside,  whilst  tumors 
distort  the  contour,  causing  irregular  bumps  or  protuberances;  and  these 
protuberances  are  often  harder  than  the  proper  uterine  structure. 

Whilst  the  tumors  are  small,  the  mobility  is  not  much  affected.  But 
when  they  become  large,  the  mobility  may  be  much  impaired  or  com- 
pletely lost.  This  is  especially  the  case  when  the  enlarged  uterus  is 
locked  in  the  pelvis.  This  immobilization  is  distinguished  from  that 
produced  by  cancer  by  the  os  and  cervix  uteri  being  felt  free  from 
disease,  by  the  absence  of  the  other  characteristic  signs  of  cancer,  and 
by  the  presence  of  the  irregular  nodosities  on  the  fundus  or  body  of 
the  uterus,  felt  above  the  pubes.  It  is  distinguished  from  the  immo- 
bilization due  to  perimetric  inflammation  by  the  history  of  this  latter 
affection  ;  by  the  seat  of  the  inflammatory  deposits  outside  the  uterus 
as  ascertained  especially  by  rectal  touch. 

Fibroid  tumor  of  the  posterior  wall  of  the  uterus  producing  retro- 
flexion, or  bulging  of  the  posterior  wall,  is  very  likely  to  be  mistaken 
for  retro-uterine  hsematocele,  or  for  simple  retroflexion  of  the  uterus. 
In  all  these  cases  a  firm  rounded  mass  is  felt  behind  the  cervix  uteri 
apparently  continuous  with  it.  Combined  rectal  and  abdominal  pal- 
pation will  help  in  the  differentiation.  But  the  sound  gives  the  clearest 
evidence.  If  the  sound  penetrate  in  the  normal  axis  of  the  uterus,  the 
hand  pressed  in  behind  the  symphysis  will  feel  the  body  of  the  uterus 
impaled  on  the  sound,  and  will  make  it  clear  that  the  mass  felt  behind 
the  cervix  is  something  else.  Retroflexion  is  also  determined  by  the 
sound  being  directed  backwards;  and  simple  retroflexion  is  made 
evident  by  our  being  able  to  lift  up  the  fundus  of  the  uterus,  thus  re- 
moving the  apparent  tumor.  This  can  rarely  be  done  if  the  apparent 
tumor  be  really  a  fibroid.  If,  when  the  sound  is  in  the  uterus,  the 
contour  of  the  body  be  explored  by  the  finger  or  hand  in  the  rectum, 
the  presence  of  tumors  may  be  made  out  with  considerable  probability 
by  the  irregular  knobbed  projections  they  produce. 

Anteversion  of  the  uterus  may  be  distinguished  by  similar  tests. 

When  tumors  are  of  large  size,  especially  if  fluctuation  can  be  made 
out  in  any  part,  the  risk  of  confounding  them  with  ovarian  tumors  is 
great.  This  point  has  been  discussed  when  studying  the  diagnosis  of 
ovarian  tumors.  One  of  the  most  characteristic  marks  of  distinction 
is  brought  out  by  the  sound.  By  the  use  of  tins  instrument  and  by 
the  finder,  we  mav  generally  in  the  case  of  ovarian  tumors  determine 
that  the  uterus  is  of  normal  size,  and  move  it  about  separately  from 
the  tumor :  and  vice  versd,  moving  the  tumor  about  by  the  hand  applied 


DIAGNOSIS.  663 

to  it  ou  the  abdomen,  we  find  that  no  movement  is  imparted  to  the 
uterus.  But  great  caution  is  necessary  in  trusting  to  these  mana?uvres. 
If  the  sound  penetrate  much  beyond  the  normal  length,  the  probability 
that  the  elongation  of  the  uterine  cavity  is  due  to  fibroid  tumors  is  very 
great.  The  best  sound  to  use  in  these  cases  is  the  whalebone  probe, 
Fig.  36,  p.  124.  This  will  follow  the  sinuosities  of  the  uterine  cavities 
Mdthout  danger  of  injuring  the  uterine  wall. 

The  diagnosis  of  retro-uterine  hematocele,  perimetric  inflammation, 
and  ovarian  tumors  has  been  carefully  discussed  in  the  chapter  treating 
of  these  subjects.  The  chief  means  of  distinction  consist  of  careful  pal- 
pation, aided  by  the  sound,  so  as  to  define  the  size  and  position  of  the 
uterus,  and  to  isolate  it  from  the  extra-uterine  tumefaction.  In  uterine 
fibroid  the  uterus,  unless  jammed  in  the  pelvis,  generally  retains  some 
degree  of  mobility ;  and  when  immovable  from  locking  in  the  pelvis, 
the  cervix  is  generally  distorted,  and  the  history  is  distinctive.  In 
perimetric  deposit  there  is  a  history  of  inflammation  dating  back  to 
labor,  abortion,  or  other  tolerably  defined  event ;  whereas  in  fibroid 
the  history  is  less  defined,  more  often  associated  with  menorrhagia,  and 
of  longer  standing. 

I  have  known  a  fibrous  tumor  in  the  bladder  simulating  fibroid  in 
the  anterior  wall  of  the  uterus  or  anteflexion.  The  sound  in  utero  and 
the  catheter  made  the  case  clear. 

McClintock  jjoints  out  that,  to  distinguish  an  ovarian  tumor  from 
uterine  tumor,  the  ulnar  edge  of  the  hand  should  be  pressed  down 
above  the  pubes.  If  the  tumor  be  ovarian,  the  edge  of  the  hand  can 
be  passed  down  deeply  between  the  tumor  and  the  pubes.  But  where 
the  tumor  is  uterine  the  hand  is  resisted,  and  cannot  be  sunk  to  any- 
thing like  the  same  extent. 

Palpation  and  the  sound  can  also  almost  always  be  relied  upon  to 
distinguish  flexions  of  the  uterus.  The  removal  of  the  tumor  by  re- 
storing the  uterus  to  its  normal  position  by  the  sound  is  distinctive  of 
flexions.  The  condition  most  likely  to  be  overlooked  is  that  where 
flexion  is  complicated  with  a  tumor.  In  this  there  is  generally  more 
or  less  marked  irregularity  in  the  shape  of  the  body  of  the  uterus. 
Bumps  or  projections  may  be  felt  on  its  peritoneal  surface  or  projecting 
into  its  cavity  ;  and  the  size  will  often  be  greater  than  is  usual  in  flexion 
or  simple  hyperplasia.  If,  in  addition,  the  cervix  be  twisted,  flattened, 
or  otherwise  distorted,  the  probability  of  the  existence  of  fibroid  tumors 
is  greatly  enhanced.  The  hardness  of  the  common  fibroid  is  peculiar : 
it  is  usually  greater  than  that  of  anything  with  which  it  is  liable  to  be 
confounded,  excepting  perimetric  inflammation ;  and  this  may  be  dis- 
criminated by  history.  It  is  distinguished  from  cancer  by  the  seat, 
which  in  cancer  is  most  frequently  in  the  cervix. 

The  diagnosis  from  pregnancy  is  a  most  important  point  to  make 
out.  Women,  the  subjects  of  tumor,  may  think  themselves,  or  be 
thought  by  others  to  be  pregnant.  In  pregnancy,  the  enlargement  of 
the  uterus  is  uniform,  thus  being  in  contrast  with  the  often  irregular 
contour  and  hardness  of  the  uterine  fibroid.  The  speculum  is  not  of 
much  value  in  giving  characteristic  signs  of  fibroid ;  but  it  is  of  great 
value  in  giving  presumptive  evidence  of  pregnancy  ;  and  thus  in  lead- 


664  FIBEOID    TUMOES, 

ing  us  to  prosecute  diagnosis  in  this  direction.  A  violet  coloration  of 
the  vagina  and  os  uteri  should  at  once  impel  to  follow  out  all  the  other 
modes  of  investigating  this  question.  The  detection  of  the  violet  color- 
ation by  rousing  suspicion  of  pregnancy  will  save  us  from  resorting  to 
the  sound.  For  this  reason  I  think  it  is  a  good  general  rule  in  prac- 
tice to  pursue  examination  in  the  following  order  :  1,  by  vaginal  touch  ; 
2,  by  speculum ;  3,  by  sound.  In  many  cases  we  shall  stop  at  the  first 
method,  or  at  the  second. 

In  doubtful  cases,  examination  by  rectum  should  never  be  omitted. 
By  this  route  the  finger  can  generally  distinguish  perimetric  effusions 
by  feeling  their  attachment  to  the  walls  of  the  pelvis,  and  by  defining 
more  accurately  the  outline  of  the  uterus. 

By  the  sound  we  can  often  make  out  the  exact  position  of  a  tumor. 
Thus  it  may  penetrate  beyond  the  normal  uterine  length  behind  or  in 
front  of  the  tumor,  which  may  then  be  felt  between  the  finger  or  hand 
by  vagina,  abdomen,  or  rectum,  and  the  sound  in  the  uterine  cavity. 
We  thus  learn  in  what  part  of  the  uterine  wall  the  tumor  is  situated. 

It  is  chiefly  when  we  have  to  deal  with  tumors  of  considerable  size, 
too  big  to  be  retained  in  the  pelvis,  that  we  have  to  make  the  diag- 
nosis from  ovarian  tumor  and  pregnancy.  The  difficulty  is  often  in- 
creased by  the  fact  that  these  large  tumors  cause  so  uniform  an  enlarge- 
ment of  the  uterus,  that  the  shape  closely  resembles  that  of  the  preg- 
nant uterus.  Having  excluded  pregnancy,  which  we  ought  always  to 
be  able  to  do,  by  carefully  collating  all  the  historical  data  and  the 
physical  signs,  positive  and  negative,  and  especially  by  the  aid  of  time, 
which  seldom  fails  to  resolve  doubts  upon  this  point,  we  may  resort  to 
the  sound.  By  help  of  this  we  may  generally  exclude  ovarian  tumors. 
If  the  sound  have  to  pursue  a  devious  course  through  the  cervix,  or  if 
it  run  to  a  distance  much  beyond  the  normal  length  along  the  direction 
of  the  tumor,  we  shall  rarely  be  wrong  in  concluding  that  the  case  is 
uterine  tumor.  Or,  if  the  mass  is  solid,  the  probability  that  it  is 
uterine  is  very  great.  It  must,  however,  be  remembered  that  in  some 
cases  of  great  enlargement  of  the  uterus  by  fibroids,  the  sound  will  not 
travel  beyond  two  or  three  inches. 

There  is  one  character  occasionally  present  in  fibroid  tumors  espe- 
cially to  be  borne  in  mind  when  the  question  lies  between  these  tumors 
and  pregnancy.  In  a  considerable,  proportion  of  cases  a  sound  resem- 
bling the  placental  sound  is  heard.  "  Sometimes,"  says  McClintock, 
"  it  is  short  and  abrupt,  a  mere  whiff  accompanying  each  arterial  pul- 
sation. At  other  times  it  is  jirolonged  and  musical,  and  not  to  be  dis- 
tinguished by  the  most  acute  and  practiced  ear  from  the  bruit  placen- 
taire"  We  should  not,  then,  declare  that  the  case  is  one  of  pregnancy 
on  the  single  evidence  of  this  sign.  Nor  is  it  likely,  if  pregnancy 
exist,  that  we  shall  be  reduced  to  this  necessity.  Almost  invariably 
some  other  confirmatory  sign  will  be  present.  The  cases  of  real  diffi- 
culty are  those  where  both  pregnancy  and  tumor  exist  together.  The 
chief  character  in  this  complication  is  the  want  of  uniformity  in  the 
shape  of  the  uterus. 

In  some  cases  of  doubtful  diagnosis  we  may  arrive  at  distinct  evi- 
dence by  dilating  the  cervix  uteri,  so  as  to  facilitate  exj)loratiou  of  the 


TEEATMENT.  665 

internal  surface  of  the  uterus.  Then  by  sound,  or  even  by  the  finger, 
we  may  feel  a  tumor  forming  a  projection  into  the  cavity,  or  we  may  by 
finger  in  the  cavity  and  combined  abdominal  palpation,  take  accurate 
note  of  the  condition  of  the  intervening  uterine  wall.  This  mode  of  ex- 
ploration is  especially  indicated  when  the  subject  is  suffering  from  hemor- 
rhages.    It  thus  becomes  a  means  of  treatment  as  well  as  of  diagnosis. 

Acupuncture,  or  the  aspirator-trocar  may  be  usefully  employed.  Dr. 
Gueniot  has  discussed  this  subject  (Arch.  Gen.  de  Med.,  1868).  He 
observes  that  it  gives  indication  as  to  sensibility,  resistance,  hardness  of 
tissue,  and  the  greater  vascular  development.  In  a  woman,  aged  fifty- 
six,  a  second  tumor  was  discovered  immediately  after  the  removal  of  a 
uterine  tumor,  the  place  of  which  it  assumed.  The  closest  examina- 
tion left  it  doubtful  whether  this  was  a  second  fibrous  polypus  or  a  partial 
inversion.  The  sound  penetrated  a  short  distance  all  round  the  tumor. 
Puncture  caused  no  pain.  It  was  concluded  to  be  a  fibrous  tumor,  and 
was  accordingly  removed  with  a  good  result. 

Diagnosis  may  be  difficult  when  the  uterus,  enlarged  by  fibroid 
tumor,  is  complicated  with  ascites.  In  this  case  a  sensation  of  hallotte- 
ment  is  felt,  differing  from  the  intra-uterine  ballottement  of  pregnancy  in 
this,  that  it  is  more  distinctly  felt  above  the  pubes  through  the  abdomi- 
nal wall. 

Malignant  tumors  of  the  lumbar  glands,  peritoneum,  and  surface  of 
the  intestines  may  also  simulate  uterine  tumors.  In  these  cases  we 
may  derive  diagnostic  indications  from  the  history  and  general  symp- 
toms. It  is  rare  for  fibroids  of  the  uterus  to  be  attended  by  such 
marked  constitutional  symptoms  as  are  commonly  observed  in  malig- 
nant disease. 

Uterine  tumors,  like  ovarian  tumors,  may  be  distinguished  from 
tumors  arising  in  the  abdominal  cavity  by  tracing  them  from  the  pelvis 
upwards.  Tumors  of  abdominal  origin  may  usually  be  traced  from 
above  downwards,  leaving  a  line  or  space  of  demarcation  at  their  lower 
margin,  which  marks  them  off  from  the  pelvis. 

In  determining  the  course  of  treatment,  especially  the  direction  of 
operative  measures,  it  is  important  to  form  an  opinion  as  to  the  part  of 
the  uterus  an  intra-uterine  tumor  grows  from.  This  may  often  be 
done  by  observing  a  character  pointed  out  by  Dr.  Kidd.  He  says  the 
uterus  bulges  out  most  in  the  wall  opposite  to  that  to  which  the  tumor 
is  attached.  So  that  feeling  a  decided  prominence,  say  of  the  anterior 
wall,  we  may  predicate  with  certainty  that  the  attachment  of  the  tumor 
is  at  the  opposite  part  of  the  uterus. 

The  Treatment  of  Tumors,  especially  Fibroids  of  the  Uterus. — In  dis- 
cussing this  question,  it  is  evidently  desirable  to  keep  in  mind  the 
properties  and  natural  history  of  these  tumors.  The  natural  termina- 
tions furnish  the  most-useful  indications.  Knowing  these  terminations 
we  may  often  assist  in  bringing  them  about.  These  terminations  we 
have  seen  are  :  1.  Absorption  or  atrophy.  2.  Calcareous  degeneration. 
3.  Gangrene  or  other  form  of  decomposition.  4.  Spontaneous  expul- 
sion or  enucleation. 

1.  Can  we  aid  or  bring  about  the  process  of  atrophy  f  This  question 
involves  the  inquiry  into  the  action  of  internal  remedies  and  local  sol- 


66Q  TUMORS    OF    THE     UTERUS. 

vent  applications.  We  have  seen  that  tumors  have  occasionally  van- 
ished under  the  influence  of  pregnancy  and  labor.  In  some  of  these 
instances  the  process  of  elimination  was  in  all  probability  inflammation 
and  breaking-down  of  the  tumor;  in  others,  detachment  and  expul- 
sion ;  but  in  others,  there  seems  no  reason  to  doubt  that  it  was  true 
absorption,  analogous  to  that  process  by  which  the  excess  of  proper 
uterine  tissue  is  removed  after  labor.  Then,  again,  there  is  the  slower 
atrophy  of  advancing  age.  Can  we  set  up  or  accelerate  similar  atro- 
phic processes  ?  Before  entering  upon  this  question  it  is  desirable  to 
discuss  a  very  important  practical  question  which  not  infrequently 
cojr.es  before  the  physician.  What  is  the  risk  of  marriage  to  a  woman 
known  to  be  the  subject  of  uterine  tumors  ?  I  have  discussed  this 
question  in  my  work  on  "  Obstetric  Operations,"  and  can  only  give 
the  general  conclusions  in  this  place.  All  authors  agree  in  the  opinion 
that  pregnancy  brings  serious  danger ;,  and  all  agree  in  discouraging 
those  who  are  the  subjects  of  uterine  tumors  from  marriage.  This  is 
certainly  the  wiser  course.  Apart  from  the  dangers  attending  preg- 
nancy, the  increased  afflux  of  blood  and  consequent  developmental 
force  excited  under  the  conditions  of  the  married  state  give  material 
imj)etus  to  the  growth  of  these  tumors.  Metrorrhagia  will  probably 
be  increased.  And,  although  fibroid  tumors  act  in  many  cases  as  an 
obstacle  to  impregnation,  still  pregnancy  often  occurs  notwithstanding. 
If  pregnancy  and  labor  are  occasionally  observed  to  be  followed  by 
the  atrophy  or  expulsion  of  the  tumors ;  and  if,  as  is  even  more  fre- 
quent, no  accident  occur  to  interrupt  the  smooth  course  of  pregnancy, 
labor  or  childbed,  the  tumors  remaining  unafiected,  the  accidents  in 
other  cases  are  so  serious  that  we  shall  rarely  be  justified  in  sanction- 
ing disregard  of  the  established  rule.  In  cases  where  we  can  clearly 
determine  that  the  tumors  are  seated  in  the  substance  and  projecting 
on  the  peritoneal  surface  of  the  fundus  of  the  uterus,  we  may  predicate 
that  the  risk  is  small.  But  where  tumors  are  found  in  the  lower  seg- 
ment, and  especially  if  projecting  into  the  cavity  of  the  uterus,  the 
danger  is  so  great  that  we  are  bound  to  prohibit  marriage  with  all  the 
authority  we  possess.  Tumors  in  this  situation  are  doubly  dangerous; 
first,  they  are  exposed  to  braising  and  tearing  during  the  passage  of 
the  child ;  secondly,  they  may  descend  before  the  child  into  the  pelvic 
cavity,  and  obstruct  labor. 

Medicines  have  been  given  with  the  four  following  designs :  1.  To 
promote  absorption  or  calcification.  2.  To  restrain  growth.  3.  To 
restrain  bleeding.     4.  To  promote  extrusion. 

Medicines  designed  to  promote  absorption  and  to  restrain  groicth  may 
fitly  be  considered  together ;  and  some  agents  which  are  chiefly  given 
for  their  supposed  efficacy  in  restraining  hemorrhage  probably  act  also 
by  promoting  extrusion.  Simpson,  Rigby,  and  others  were  very  posi- 
tive as  to  the  absorption  of  fibroids.  Simpson  says  they  are  sometimes 
seen  in  fatty  metamorphosis.  Spencer  Wells  observes  that  no  one 
could  expect  a  true  fibrous  tumor  to  disappear  spontaneously;  but  mus- 
cular tumors  rapidly  grow  and  rapidly  disappear.  He  expresses  him- 
self as  astonished  to  find  that  doubts  are  entertained  as  to  the  fact  of 
their  disappearance.     The  cellular  spaces  between  the  fibres  of  these 


TREATMENT.  667 

tumors  may  become  filled  with  serum ;  and  that  portion  of  the  tumor 
thus  due  to  oedema  may  undoubtedly  disappear.  In  such  cases  Wells 
thinks  the  use  of  bichloride  of  mercury  is  often  followed  by  remark- 
able diminution.  Simpson  praised  the  bromide  of  potassium.  Where 
there  is  much  irregular  bleeding,  Wells  agrees  with  McClintock  in 
regarding  chloride  of  calcium  as  of  great  value.  This  remedy  had 
been  introduced  by  Rigby  in  1846.  He  says  he  "found  that,  if  com- 
menced in  5?s.  doses  of  the  solution  twice  a  day,  the  patient  could 
gradually  increase  it  until  she  had  reached  5j  without  inconvenience. 
After  continuing  at  this  dose  for  a  month,  she  left  it  off  for  a  few 
weeks,  and  again  resumed  it  as  before ;  a  decided  change  was  observ- 
able in  several  cases."  McClintock  relates  a  case  in  which  complete 
cure  was  effected  by  this  remedy  combined  with  perchloride  of  iron. 
Wells,  however,  has  found  that,  if  persisted  in  for  a  length  of  time, 
the  chloride  of  calcium  is  apt  to  bring  about  calcareous  degeneration 
of  the  arteries  generally ;  and  this  is  so  real  a  danger  that  the  remedy 
must  be  used  with  great  caution.  Its  action  in  arresting  the  growth 
of  fibroids  probably  depends  upon  this  property.  The  tumor  perhaps 
has  a  greater  affinity  for  the  chloride  of  calcium  than  have  other  struc- 
tures ;  and  if  the  calcareous  deposit  could  be  limited  to  it,  the  remedy 
would  be  without  a  drawback. 

Rigby  further  possessed  great  faith  in  the  Kreuznach  water.  Adopt- 
ing the  suggestion  of  Dr.  O.  Prieger,  he  tried  this  water  in  a  very  con- 
centrated form,  and  believed  he  increased  its  efficacy  by  adding  from 
two  to  five  grains  of  bromide  of  potassium.  "In  many  cases,"  Rigby 
says,  "the  results  have  been  very  successful;  in  some,  where  this  arti- 
ficial mineral  water  formed  the  sole  treatment;  in  others,  where  it  was 
combined  with  the  local  application  of  leeches  and  mercurial  ointment." 

The  remedies  applied  in  the  hope  of  restraining  growth  are  the  same 
as  those  designed  to  promote  absorption.  It  may  be  reasonably  ex- 
pected that  greater  success  would  be  attained  in  accomplishing  this 
lesser  result.  Observations  upon  this  point  are,  however,  even  more 
fallacious.  If  we  can  demonstrate  a  sensible  diminution  in  the  bulk 
of  a  tumor,  and  even  follow  the  diminution  on  to  complete  disappear- 
ance, the  only  doubt  as  to  the  reality  of  absorption  rests  on  the  possi- 
bility of  an  original  error  of  diagnosis.  The  supposed  tumor  might 
have  been  retro-uterine  ha3matocele,  an  enlarged  body  of  the  uterus 
from  hyperplasia,  or  some  other  condition.  That  some  cases  of  cure 
by  absorption  reported  before  the  characters  of  retro-uterine  hsematocele 
were  known  were  falsely  interpreted  is  highly  probable.  But  the 
reality  of  fibroid  tumors  having  been  absorbed  is  too  well  established 
to  admit  of  doubt.  It  does  not,  however,  follow  that  this  absorption 
was  due  to  the  remedies  employed.  In  some  cases  of  absorption  no 
treatment  deserving  consideration  was  adopted.  And  in  the  rest  in 
which  internal  remedies  were  used,  doubt  as  to  their  share  in  the  result 
is  not  unjustifiable.  My  own  experience  lends  little  or  no  support  to 
the  proposition  that  internal  remedies  exert  any  influence  in  promoting 
absorption  of  the  hard  fibroid  tumor.  I  suspect  that  the  favorable 
opinions  as  to  their  efficacy,  which  some  authors  have  expressed,  spring 
from  the  observation  of  the  larger,  looser-textured  tumors,  and  that  the 


668  TUMORS    OF    THE    UTERUS. 

diminntion  was  due  to  the  absorption  of  fluid  infiltration,  the  solid  con- 
stituent remaining  untouched. 

West  and  S(!anzoui  doubt  whether  the  Kreuznach  waters  have  cured 
a  single  case. 

Sustained  elastic  pressure,  as  by  means  of  an  abdominal  belt,  may  be 
useful  in  promoting  the  absorption  of  infiltrated  fluid.  It  is  doubtful 
whether  it  exerts  much  influence  in  diminishing  the  solid  constituents. 
It  may,  however,  be  useful  in  supporting  the  mass,  and  in  preventing 
injurious  dragging. 

The  ergot  of  rye  has  also  been  used  with  this  indication.  It  has 
been  supposed  that  nutrition  might  be  arrested  by  the  constricting 
action  of  the  ergot  upon  the  vessels  feeding  the  tumor ;  and  by  the 
compression  exerted  upon  the  tumor  by  the  contraction  of  the  muscular 
wall.  Hildebrandt  (Berlin  Klin.Wochenschr,  1872)  treated  nine  cases 
by  the  subcutaneous  injection  of  ergotin.  "In  four,"  he  says,  "the 
diminution  of  the  tumor  was  free  from  doubt ;  in  the  others  trouble- 
some symptoms  subsided." 

But  more  frequently  ergot  has  been  used  with  the  object  of  promot- 
ing the  expulsion  of  the  tumor. 

The  fallacies  which  weaken  any  conclusion  as  to  the  influence  of 
remedies  in  arresting  the  growth  of  fibroid  tumors  are:  1.  That  these 
tumors  are  often  of  extremely  slow  growth,  so  that  any  change  in  size 
within  even  a  considerable  time  would  be  difficult  to  appreciate,  and 
still  more  to  prove.  2.  That  many  of  these  tumors,  when  they  have 
reached  a  certain  size,  exhibit  no  tendency  to  increase,  but  remain  sta- 
tionary, although  no  treatment  is  employed.  3.  That  in  a  large  num- 
ber of  instances  there  is  a  natural  tendency  towards  inertness  or  even 
retrogression  after  the  climacteric;  and  that  since  these  tumors  fre- 
quently do  not  come  under  treatment  until  this  period  is  approaching, 
such  treatment  may  be  merely  coincident  with  the  natural  process  of 
cure,  not  conducive  to  it.  And,  lastly,  the  most  persistent  use  of  reme- 
dies in  many  cases  has  not  been  followed  by  any  sensible  alteration  in 
the  hands  of  many  competent  observers. 

The  effects  of  mechanical  pressure  may  sometimes  be  obviated  by  lift- 
ing the  tumor  out  of  the  pelvis.  The  uterus  with  its  parasitic  growths 
may  be  movable  en  masse.  Sometimes  the  hand  in  the  vagina  or  rec- 
tum may  liberate  the  pelvis.  But  more  often,  a  method  used  with 
success  by  Dr.  G.  H.  Kidd  is  better.  The  patient  is  placed  in  knee- 
elbow  position,  and  one  of  my  dilating-bags  is  placed  in  vagina  or  rec- 
tum, which,  made  to  expand  below  the  tumor,  gradually  raises  it. 
This  proceeding  would  also  be  effectual  by  relieving  the  bowel  from 
obstruction,  in  removing  the  flatulent  distension  which  sometimes  drives 
the  tumor  down  into  the  pelvis.  Or,  where  flatulence  is  extreme,  and 
the  tumor  cannot  be  moved  or  extirpated,  relief  may  be  given  by  punc- 
ture by  a  fine  trocar  into  the  intestine,  as  was  done  by  Dr.  Kidd.  In 
a  case  he  relates  a  great  escape  of  gas  took  place.  A  candle  brought 
near  the  gas  took  fire,  burning  with  a  blue  flame.  Next  day  the 
bowels  acted  freely. 

Treatment  designed  to  restrain  hemorrhage  may  fitly  be  considered 
in  connection  with  that  designed  to  promote  absorption  or  to  check 


TREATMENT.  669 

growth  of  fibroid  tumors.  Treatment  for  this  purpose  consists  of  in- 
ternal remedies,  of  local  applications,  and  of  surgical  operations.  The 
principal  internal  remedies  have  been  already  described.  To  chloride 
of  calcium  and  ergot  may  be  added  strychnine,  quinine,  digitalis,  tur- 
pentine, Indian  hemp,  the  lead  and  opium  pill,  alum  and  gallic  acid — 
all  agents  of  unquestionable  efficacy  as  haemostatics.  They  now  and 
then  act  satisfactorily,  but  much  more  often  they  fail.  Small  doses  of 
mercury  have  in  some  cases  been  attended  with  success. 

Local  styptics,  on  the  other  hand,  may  almost  always  be  relied  upon 
to  stop  hemorrhage  for  the  time.  Of  these  the  best  are,  perchloride 
or  persulphate  of  iron,  chromic  acid  and  nitric  acid,  or  iodine.  Their 
efficacy  depends  upon  their  being  applied  directly  to  the  bleeding  sur- 
face, that  is,  to  the  mucous  membrane  of  the  uterus,  as  well  as  to  that 
immediately  covering  the  tumor.  To  accomplish  this,  it  is  necessary 
in  the  first  place  to  obtain  free  dilatation  of  the  cervix  uteri.  This 
preliminary  dilatation  can  be  effected  by  means  of  laminaria  or  sponge- 
tents  left  in  for  several  hours,  or  by  incisions  of  the  cervix.  If  the 
canal  is  tortuous,  incisions  will  be  necessary,  at  least  in  the  first  in- 
stance; and  sometimes  it  will  be  desirable  to  resort  to  both  incisions 
and  tents. 

It  is  a  remarkable  fact  that  dilatation  of  the  cervical  canal  alone  is 
in  many  cases  followed  by  arrest  of  hemorrhage.  Baker  Brown, 
N^laton,  and  McClintock  have  established  this  fact  as  to  the  effect 
of  incisions  in  the  cervix.  I  have  in  so  many  instances  practiced 
this  operation  with  advantage  that  I  entertain  no  doubt  of  its  value. 
It  does  not  appear  to  be  necessary  that  the  tumors  themselves  should 
be  cut  into.  Simple  dilatation  by  laminaria-tents  is  often  efficacious. 
The  incisions  should  not  be  deep ;  they  should  especially  not  be  carried 
deeply  into  the  neck  at  the  level  of  the  os  internum.  Incisions  made 
in  this  way  have  appeared  to  me  to  exercise  a  beneficial  effect  in  modi- 
fying the  nutrition  of  fibroid  tumors;  a  free  os  uteri  externum  will 
often,  as  we  have  seen,  when  studying  the  history  of  dysmenorrhoea 
and  menorrhagia,  relieve  these  symptoms.  I  have  acquired  the  con- 
viction that  these  incisions  have  even  arrested  the  growth  and  promoted 
the  absorption  of  uterine  fibroids. 

But  supposing  that  dilatation,  whether  by  knife  or  tents,  is  not  fol- 
lowed by  arrest  of  bleeding,  the  road  being  open,  v/e  now  apply  the 
styptic.  This  is  best  done  by  means  of  a  swab.  A  probe  mounted 
on  a  wooden  handle,  or  the  instrument  made  to  carry  nitrate  of  silver 
(see  Fig.  42,  p.  129)  answers  perfectly.  Around  the  end  a  little 
cotton-wool  is  twisted  ;  this  is  steeped  in  the  styptic  fluid,  and  carried 
quite  into  the  cavity  of  the  uterus  and  pressed  steadily  against  the 
inner  surface.  It  is  desirable  to  have  three  or  four  of  these  probes 
mounted  with  cotton- wool,  using  one  or  two  of  them  first  to  wipe  out 
the  blood  from  the  interior  of  the  uterus  before  introducing  the  styp- 
tic. To  facilitate  this  introduction,  and  to  obviate  the  inconvenience  of 
losing  much  of  the  action  of  the  styptic  in  its  passage  along  the  cervix, 
we  may  resort  to  one  of  two  expedients.  Using  a  jSTeugebaiier's  or  a 
Cusco's  speculum,  both  of  which  bring  the  os  uteri  down  within  easy 
sight  and  reach,  seize  the  margin  of  the  os  with  a  Sims's  hook  or  a 


670  TUMORS    OF    THE     UTERUS. 

vulsellum,  so  as  to  steady  and  hold  oj)en  the  cervix  for  the  passage  of 
the  styptic ;  or  insert  a  cervical  tube,  such  as  those  designed  by  Dr. 
Lombe  Atthill  and  myself.  This  serves  as  a  protecting  channel  along 
which  the  styptic  can  be  passed  direct  into  the  uterus. 

The  perchloride  or  persulphate  of  iron  should  be  used  very  strong, 
nearly  concentrated.  The  chromic  acid  crystals  should  be  simply 
moistened  with  a  little  water.  This  is  a  very  powerful  styptic.  The 
nitric  acid  should  be  used  fuming.  The  acid  mostly  acts  as  a  superfi- 
cial styptic  or  caustic.  But  Dr.  Gogarty  relates  a  successful  case 
(Medical  Press,  1871)  in  which  the  "lining  membrane  was  denuded, 
and  it  came  away  a  perfect  cast  of  the  uterine  face  of  the  tumor." 

Dr.  Savage  extols  strong  tincture  of  iodine.  If  we  find  swabbing 
inefficacious  or  not  to  be  carried  out,  then  the  best  thing  to  do  is  to  in- 
ject a  solution  of  persulphate  or  perchloride  of  iron.  Of  course  it 
is  eminently  desirable  that  the  cervix  should  be  dilated;  but  we  are 
supposing  this  not  feasible,  and  that  the  hemorrhage  is  so  serious  as  to 
threaten  life.  In  such  a  case  a  vulcanite  tube  may  be  passed  into  the 
uterus,  and  two  or  three  ounces  of  a  solution  of  perchloride  of  iron  or 
of  the  persulphate  may  be  injected  by  means  of  an  india-rubber  ball 
which  can  be  adapted  to  the  tube.  This  will  rarely  fail.  I  have  saved 
several  lives  by  this  treatment.  Dr.  Kidd,  I  am  bound  to  state,  says 
that,  "in  his  experience  the  injection  of  perchloride  of  iron  is  the  least 
useful  and  the  most  dangerous  treatment.  The  last  case  in  which  he 
ti'ied  it  proved  fatal.  The  woman  got  a  low  form  of  metritis  and  died." 
I  have  not  myself  seen  any  ill  effect  from  it.  In  my  "  Obstetric  Ope- 
rations" I  have  cited  in  detail  the  history  of  a  case  ending  fatally  from 
injection  of  perchloride  of  iron  into  a  uterus  dilated  by  retroflexion. 
But  surely  we  ought  not  to  be  deterred  by  this  risk  from  the  imme- 
diate and  urgent  duty  of  saving  a  woman  from  bleeding  to  death. 

Should  bleeding  have  brought  the  patient  to  extremity,  there  is  still 
a  resource  in  transfusion.  Dr.  Gentilhomme  relates  an  interesting  case 
(Gazette  Hebdomadaire,  1868)  in  which  life  was  saved  by  this  ope- 
ration. 

The  preceding  means  should  be  steadily  jjersevered  in,  combating 
symptoms  as  best  we  can,  striving  to  support  the  patient  against  them 
until  the  climacteric  period,  when  we  may  reasonably  hope  that  the 
tumors  will  pass  into  degeneration  or  atrophy,  or  at  any  rate  become 
inert.  It  is  only  when  the  patient's  condition  is  so  serious  that  we 
cannot  afford  to  temporize,  and  these  means  can  no  longer  be  trusted 
to,  that  we  shall  be  justified  in  resorting  to  the  more  decided  but  more 
hazardous  surgical  proceedings  which  we  have  now  to  discuss. 

We  have  lastly  to  consider  the  means  of  getting  rid  of  the  tuinors 
altogether.  This  embraces  the  discussion  of  the  various  proceedings 
available  for  promoting  their  expulsion ;  for  causing  their  destruction 
and  elimination  by  setting  up  inflammation  or  necrosis ;  for  ablation 
by  enucleation,  avulsion,  ligature,  knife,  scissors,  ecraseur,  cautery; 
and  for  removing  the  uterus  itself  along  with  the  tumors  by  gas- 
trotomy. 

The  idea  of  enucleation  seems  to  have  been  first  clearly  discussed  by 


TEEATMENT.  671 

Velpeau.     It  was  practiced  by  Araussat,  and  has  beeu  rather  exten- 
sively tried  of  late  years. 

The  means  for  bringing  about  enucleation  and  expulsion  may  be 
conveniently  described  together.  The  larger  tumors,  whose  texture  is 
continuous  with  the  uterine  Avail,  are  not  proper  subjects  of  these  pro- 
ceedings. It  is  from  not  bearing  in  mind  this  fact,  which  has  been  so 
distinctly  insisted  upon  by  Rigby  and  McClintock,  that  failure  and 
disaster  have  so  often  followed  surgical  proceedings.  And  since  the 
difficulty  of  diagnosis  between  these  and  the  encapsuled  tumors  is  great, 
the  subject  is  involved  in  doubt  at  the  very  threshold.  These  pro- 
cesses, then,  are  chiefly,  if  not  exclusively  applicable  to  the  hard  fibroid 
bodies  which  are  encapsuled.  Expulsion  may  l)e  accomplished  with- 
out enucleation.  This  occurs  in  those  cases  where  the  tumor  is  thrust 
out  of  the  wall  of  the  uterus,  becoming  a  polypus.  A  polypus  after 
hanging  for  a  time  by  a  pedicle,  may  be  thrown  off  altogether,  a  thin 
capsule  of  uterine  tissue  carried  before  it  still  investing  it.  Or  expul- 
sion may  be  effected  by  spontaneous  enucleation.  The  investing  cap- 
sule may  ulcerate,  and  uterine  contraction  going  on,  the  tumor  loosened 
may  be  thrown  out. 

These  processes  of  expulsion  may  be  aided  by  the  use  of  so-called  oxy- 
tocic remedies.  Treating  the  tumor-bearing  uterus  as  we  would  the 
childbearing  organ,  we  give  certain  remedies  that  possess  the  property  of 
provoking  or  strengthening  the  uterus  to  contract.  The  chief  of  these 
are  ergot,  quinine,  strychnine,  g-alvanism.  The  action  of  these  agents 
upon  the  uterine  muscle,  even  in  the  non-pregnant  state,  is  undoubted. 
But  they  cannot  be  expected  to  act  so  efficiently  as  in  pregnancy  M'hen 
the  mhscular  fibre  is  highly  developed,  and  when  the  nervous  centres 
are  in  a  peculiar  state  of  tension  ready  to  respond  to  comparatively 
slight  excitation.  The  remedies  must  therefore  be  given  over  a  con- 
siderable space  of  time.  And  generally  they  cannot  be  trusted  to 
alone.  It  is  conuiionly  necessary  to  dilate  the  cervix  freely  by  inci- 
sions and  tents;  and  if  we  find  the  tumor  or  tumors  projecting  into  the 
uterine  cavity,  to  seize  them  with  a  vulsellum,  to  draw  them  down,  to 
try  enucleation  by  scratching  through  the  capsule  at  the  margin  of 
uterine  attachment,  or  even  by  aid  of  scissors  making  nicks  into  its 
substance.  Under  this  manipulation  of  combined  traction  and  inci- 
sions, the  tumor  will  sometimes  come  away.  But  this  result  will 
rarely  be  accomplished  at  the  first  trial.  Several  sittings  may  be 
necessary. 

Where  the  tumors  seized  with  the  vulsellum  cau  be  surrounded  at 
the  base  with  a  wire,  it  is  best  to  remove  what  we  can  by  the  ecraseur. 
In  some  cases  if  the  loop  of  wire  can  be  made  to  bite  beyond  the 
equator  or  greatest  diameter  of  the  tumor,  when  the  screw  is  turned  on, 
the  loop  naturally  closing  in  on  the  farther  or  uterine  side  may  actu- 
ally effect  enucleation. 

The  wire  used  for  this  purpose  should  be  firm,  like  a  piano-cord,  of 
steel,  so  that  the  loop  can  be  passed  into  the  uterus  compressed  in  an 
elongated  form,  and  will  open  out  again  when  released  from  pressure 
into  an  oval  or  circular  shape  that  will  run  over  the  tumor.  Carried 
in  an  Ecraseur  the  end  of  this  instrument  is  pushed  on  to  the  base  of 


672  TUMORS    OF    THE    UTERUS. 

the  tumor,  whilst  a  finger  applied  to  the  wire-loop  guides  this  down 
over  the  tumor  until  it  has  got  beyond  the  greatest  diameter;  and  then 
the  loop  is  drawn  in  by  the  screw  and  made  to  divide  the  tumor  at  its 
base.  The  tumor  may  then  be  taken  out  by  the  vulsellum  or  the 
fingers.  When  the  wire-loop  cannot  be  slipped  over  the  tumor  by  the 
finger,  it  is  convenient  to  use  a  little  crutch  on  a  long  stem,  which 
seizing  the  wire  can  be  made  to  push  it  up  towards  the  fundus  of  the 
uterus. 

Under  the  "Treatment  of  Polypus"  is  a  figure  illustrating  the  ap- 
plication of  the  wire  ^craseur. 

Enucleation  failing,  the  tumor  will  be  divided  by  the  wire  flush 
with  the  inner  surface  of  the  uterus.  Then  one  of  three  things  may 
happen:  1.  The  tumor  may  heal,  cicatrize  at  the  incised  surface;  but 
the  hemorrhage  will  in  all  likelihood  cease,  and  relief  be  gained  for 
a  time.  2.  Slow  inflammation  or  necrosis  is  set  up  in  the  attached 
portion  of  the  tumor,  and  its  capsular  attachments  losing  their  vitality, 
the  tumor  is  cast  out.  During  this  process,  there  is  sometimes  con- 
tinuance of  pain  due  to  the  spasmodic  action  of  the  uterus,  offensive 
serous  discharge,  and  possibly  some  degree  of  irritative  fever.  All 
this  trouble  ceases  when  the  residuum  of  the  tumor  is  expelled.  3.  In- 
flammation may  extend  from  the  tumor  to  the  uterus  itself,  and  pysemia 
added  to  metritis  may  try  the  constitution  to  the  utmost.  But  this 
third  event  is  exceptional.  These  tumors  bear  a  great  deal  of  rough 
handling  without  entailing  any  serious  consequences. 

In  some  cases  enucleation  of  even  large  tumors  may  be  effected  by 
the  hand  alone  or  aided  by  the  knife  or  scissors.  After  free  dilatation 
of  the  cervix  has  been  secured,  a  hernia-knife  guided  by  a  finger  in  utero 
makes  a  long  incision  into  the  projecting  part  of  the  tumor  dividing 
the  capsule.  Then  the  finger  insinuated  between  the  solid  tumor  and 
its  investment  may  shell  it  out. 

In  other  cases  more  diflicult,  we  may  succeed  in  removing  a  large 
tumor,  one  even  too  large  to  be  drawn  unaltered  through  the  pelvis,  by 
the  process  called  spiral  elongation.  Seizing  the  most  accessible  part 
of  the  tumor  by  a  vulsellum,  and  by  its  means  dragging  the  tumor  as 
near  the  vulva  as  possible,  aided  by  supra-pubic  pressure  by  an  assistant, 
a  series  of  incisions  are  made  in  the  tumor  in  a  spiral  or  oblique  direc- 
tion. Under  the  combined  effect  of  dragging  and  these  incisions  the 
tumor  is  drawn  out,  it  elongates,  so  that  fresh  incisions  can  be  carried 
successively  into  higher  parts  of  it,  until  we  reach  the  last  part,  when 
all  comes  away.     I  have  practiced  this  operation  successfully. 

SoQietimes  the  removal  of  a  tumor  can  only  be  effected  piecemeal. 
Wedge-shaped  pieces  are  cut,  or  torn  away,  or  the  ^craseur  takes  away 
portions  successively.  In  this  manner,  removing  gradually  the  ob- 
structing parts  of  the  tumor,  we  work  towards  the  base. 

Bleeding  seldom  complicates  these  proceedings  in  a  dangerous  degree. 
When  it  is  at  all  copious  it  may  be  arrested  by  swabbing  the  surface 
with  nitric  or  chromic  acid. 

It  has  been  sought  to  bring  about  the  destruction  of  a  fibroid  tumor 
and  its  enucleation  by  the  action  of  caustics.  Simpson  thus  made  an 
opening  in  the  capsule  of  a  tumor  at  the  most  depending  point ;  ergot 


TEEATMENT.  673 

then  exciting  uterine  contraction,  the  tumor  was  gradually  driven  down 
through  the  opening  and  it  was  eventually  taken  away  by  the  hand. 
The  patient  died  on  the  sixth  day  of  pyaemia. 

Dr.  Atlee,  in  a  "  Report  on  the  Surgical  Treatment  of  certain  Fi- 
brous Tumors  of  the  Uterus  heretofore  considered  beyond  the  resources 
of  art,"  published  in  1854,  described  a  method  for  bringing  about  de- 
struction by  disintegration  of  the  tumor  as  a  part  of  the  process  of 
enucleation.  ''A  section  made  through  their  thin  investing  membrane 
will  sometimes  be  followed  by  the  death  of  the  whole  mass.  This  may 
be  owing  to  the  admission  of  air  causing  it  to  degenerate.  Indeed  it 
M'^ould  appear  that  the  action  of  the  oxygen  of  the  air,  like  a  portion 
of  yeast  in  a  fermentable  mass,  may  originate  in  any  part  of  a  fibrous 
tumor  an  action  of  eremacausis  which  may  extend  throughout  the 
whole."  It  is  needless  to  discnss  the  theory  here  expressed  as  to  the 
process  by  which  the  vitality  of  the  tumors  is  destroyed.  The  impor- 
tant point  is  to  examine  the  results.  The  history  of  the  cases  reported 
in  this  memoir  did  not  afford  much  encouragement  to  follow  the  prac- 
tice. 

Allied  to  Dr.  Atlee's  plan  is  that  of  Baker  Brown,  which  consists  in 
gouging  or  excavating  a  piece  of  the  tumor.  The  efFect  is  in  most 
cases  to  cause  necrosis.  It  is  easy  to  set  up  this  process.  It  is  not 
easy  to  limit  it ;  and  death  has  resulted  from  the  extension  of  inflam- 
mation to  the  uterus,  and  pysemia. 

If  decomposition  of  a  tumor  have  begun,  and  constitutional  symp- 
toms of  irritation  from  absorption  appear,  a  decided  attempt  at  least 
should  be  made  to  bring  away  the  tumor.  The  patient  being  under 
chloroform,  the  hand  in  utero  may  effect  detachment  unaided,  or  scissors 
may  be  used  to  divide  any  bands  or  connections.  Dr.  Grimsdale  and 
Mr.  Bickersteth,  of  Liverpool,  thus  undoubtedly  saved  a  life  immi- 
nently threatened.  The  woman  afterwards  became  pregnant.  (Liver- 
pool Med.-Chir.  Journ.,  1857.) 

Pean  and  Urdy^  trace  the  history  of  gastrotomy  for  the  removal  of 
uterine  tumors  through  three  distinct  periods.  The  first,  which  comes 
down  to  1843,  comprises  those  cases  in  which  surgeons  having  opened 
the  abdomen  with  a  view  to  ovariotomy,  finding  the  tumors  to  be  uter- 
ine, shrank  before  the  consequences  of  amputation  of  the  uterus,  and 
closed  the  wound.  In  the  second  period,  that  of  trials  and  groping, 
which  coiiics  down  to  1863,  during  which  ovariotomy  had  made  great 
strides,  several  surgeolis,  Atlee,  Heath,  Charles  Clay,  Parkinson,  find- 
ing uterine  tumors  where  they  expected  ovarian,  yet  did  not  hesitate 
to  remove  the  uterus.  In  the  third  period,  beginning  with  April,  1863, 
Koeberle,  in  the  presence  of  a  doubtful  case,  prepared  for  either  ovari- 
otomy or  hysterotomy.  Storer,  Pean,  and  others  deliberately  resorted 
to  gastrotomy  for  the  purpose  of  removing  the  uterus  affected  by  tu- 
mors. 

Between  September,  1869,  and  February,  1872,  Pean  had  performed 
the  operation  five  times  for  fibrous  tumors  of  the  uterus,  and  four  times 

1  "  Hysterotomie :  Etude  sur  les  tumeurs  qui  peuvent  n^cessiter  cette  operation." 
Paris,  1873. 

43 


674  TUMORS    OF    THE    UTERUS. 

for  fibro-cystic  tumors,  with  the  result  of  two  deaths  out  of  the  nine 
cases.  One  death  is  ascribed  to  retro-uterine  hsematocele  on  the  elev- 
enth day  ;  the  other  to  shock,  fifty-seven  hours  after  the  operation. 
He  gives  a  table^  intended  to  be  complete,  of  forty-four  cases  performed 
down  to  1872,  including  those  of  Koeberle,  of  which  fourteen  re- 
covered, and  thirty  died.  To  this  list,  however,  I  might  object  that  I 
have  myself  seen  one  fatal  case,  which  is  not  recorded  in  it,  and  could 
easily  add  others  from  various  sources. 

Before  performing  the  operation  the  same  general  preparations  which 
are  practiced  before  performing  ovariotomy  are  indicated.  The  time 
to  be  selected  should  be  within  a  week  after  a  menstrual  period. 

The  instruments  required  are  the  same  as  for  ovariotomy.  But  there 
should  be  provided  in  addition  several  powerful  serre-noeuds,  such  as 
those  of  Dr.  Cintrat,  and  wires  of  different  sizes. 

Since  much  cannot  be  gained  by  lessening  the  bulk  of  the  tumor, 
the  abdominal  incision  must  generally  be  longer  than  is  necessary  for 
ovariotomy.  When  the  tumor  comes  into  view,  the  extent  to  which 
its  volume  can  be  lessened  must  be  considered.  If  there  are  cysts, 
these  must  be  punctured.  If  it  is  solid,  and  too  big  to  come  through 
the  wound,  the  process  of  cutting  up,  "  morcellement "  of  the  tumor 
must  be  resorted  to.  This  is  effected  by  piercing  the  middle  part  of 
the  tumor,  or  if  that  cannot  be  done,  the  most  accessible  part,  by  several 
metallic  wires,  and  tightening  them  by  serre-noeuds.  These  serre-noeuds 
resemble  small  wire  ecraseurs.  The  circulation  through  the  part  above 
the  ligatures  being  thus  stopped,  this  part  may  be  freely  cut  away,  and 
the  surgeon  may  proceed  to  deal  with  the  rest. 

Pean  insists  that  the  success  of  the  operation  depends  upon  securing 
the  peritoneum  from  the  entry  of  fluids  into  it.  Hence  if  a  cyst  is  to 
be  opened  it  is  first  drawn  outside  the  abdomen.  In  separating  adhe- 
sions like  care  is  extended,  to  obviate  bleeding  into  the  peritoneum. 
Small  bleeding  vessels  are  tied  with  silk,  and  the  ends  cut  short.  The 
actual  cautery  by  aid  of  the  cautery-clamp  should  be  used  to  sever 
parietal  or  omental  adhesions. 

When  the  tumor  has  been  drawn  out  of  the  abdomen  the  question  of 
how  best  to  amputate  it  will  be  decided  by  the  conditions  of  its  connec- 
tions. If  attached  by  a  small  pedicle,  it  may  be  clamped  like  an 
ovarian  tumor,  or  ligatured  by  traversing  the  pedicle  by  two  wires  or 
pieces  of  whip-cord  to  be  drawn  tight  by  serre-noeuds.  If  the  pedicle 
be  large,  and  have  a  very  broad  attachment  to  the  uterus,  it  becomes  a 
question  whether  the  immediately  involved  part  of  the  uterus  or  a 
greater  part  of  the  organ  shall  be  removed.  Pean  advises  in  this  case  to 
remove  the  uterus  at  the  neck.  Besides  having  lost  two  cases  in  which 
he  confined  himself  to  removing  only  a  part,  whilst  he  saved  those  in 
which  he  practiced  amputation  at  the  neck,  he  gives  the  following  good 
reasons  for  adopting  the  latter  course :  In  the  cases  which  compel  re- 
sort to  gastrotomy,  the  uterus  is  always  hypertrophiecl,  perhaps  other- 
wise diseased;  a  much  larger  surface  must  be  divided  and  exposed  in 
removing  a  ])art  of  the  body  of  the  uterus  than  by  amputating  at  the 
neck,  laying  open  large  sinuses,  which  fiivor  pyremia;  and  the  supra- 
vaginal amputation  is  really  easier. 


EXTIRPATION     OF    THE     UTERUS.  675 

In  another  class  of  cases  the  relations  of  the  tumor  are  such  that 
there  is  no  choice  but  to  remove  the  whole  uterus.  By  catheter  in  the 
bladder  the  relation  of  this  organ  to  the  neck  of  the  uterus  is  made  out; 
this  part  is  traversed  by  two  straight,  rigid  needles,  perpendicularly  to 
each  other,  preserving  as  long  a  pedicle  as  convenient.  This  done,  a 
strong  curved  needle  notched  at  the  end  is  passed  through  the  pedicle 
or  uterine  neck  immediately  above  the  most  superficial  of  the  two  straight 
needles  traversing  the  pedicle.  The  notch  catches  a  metallic  thread 
which,  being  brought  through  by  its  loop,  forms  a  double  ligature. 
These  are  then  tightened  by  the  serre-noeud.  If  the  part  be  very  vas- 
cular another  ligature  jnay  be  passed  beneath  the  two  straight  needles. 
The  uterus  may  then  be  removed.  There  is  no  valid  reason  against 
removing  the  ovaries  along  with  the  uterus.  The  end  of  the  stump  is 
brouo;ht  outside  the  abdomen,  the  four  ends  of  the  straio-ht  transfixins; 
needles  and  the  ligatures  rest  upon  the  abdominal  wound,  and  the 
wound  is  closed  as  after  ovariotomy.  The  after-treatment  resembles 
that  for  ovariotomy. 

Pean  at  the  close  of  this  very  practical  clinical  memoir  presents  the  two 
following  conclusions:  1.  Fibrous  or  fibro-cystic  tumors  of  the  uterus 
having  reached  a  certain  degree  of  development  may  cause  serious  ac- 
cidents capable  of  entailing,  sooner  or  later,  certain  death.  In  these 
circumstances  the  surgeon  is  not  only  right  in  performing  gastrotomy, 
but  it  is  his  duty  to  do  it.  2.  If  the  connections  of  the  tumor  with 
the  uterus  are  ever  so  little  intimate,  it  is  better  to  amputate  the  body 
of  the  uterus  without  attempting  to  preserve  the  ovaries,  than  to  seek 
to  enucleate  the  tumor. 

The  justification  for  attempting  enucleation,  avulsion,  or  other  mode 
of  removing  large  fibroid  tumors  will  rest  upon — 1.  Uncontrollable 
hemorrhages  endangering  life  ;  2.  Signs  of  sloughing  or  decomposition 
of  the  tumor,  with  present  or  threatening  peritonitis  or  pyaemia;  3. 
Dangerous  pressure  upon  the  bladder  and  rectum. 

The  same  conditions  threatening  life,  and  removal  by  the  processes 
above  enumerated  being  precluded,  may  justify  the  last  resource,  that 
of  gastrotomy. 

The  case  is  analogous  to  dystocia.  If  we  cannot  effect  delivery 
through  the  pelvis,  we  resort  to  gastrotomy.  And  this  must  be  the 
rule  of  action  in  dealing  with  uterine  fibroids,  assuming  always  that 
extirpation  is  necessary. 

The  time  has  not  yet  come  for  forming  a  confident  opinion  upon  the 
practice  of  gastrotomy  for  the  removal  of  uterine  fibroids  either  alone 
or  with  the  uterus.  At  present  there  is  little  ground  for  enthusiastic 
advocacy  of  the  practice.  The  case  may  best  be  summed  up  by  stating 
that  the  question  is  adhuc  sub  judice.  We  must  for  awhile  be  content 
with  the  divided  opinions  expressed  in  the  Academy  of  Medicine  on 
the  occasion  of  a  report  presented  by  Demarquay  on  Memoirs  by  Koe- 
berle,  who  advocates  the  proceeding,  and  by  Boinet,  who  condemns  it. 
Boinet  showed  that  the  operation  had  for  the  most  part  been  performed 
accidentally  in  cases  mistaken  for  enlarged  ovary  ;  that  it  could  not  be 
defended  on  the  same  grounds  as  ovariotomy ;  that  it  should  always  be 
rejected  when  the  tumor  was  not  pedunculated,  and  especially  when 


676  POLYPUS  OF  THE  UTERUS. 

it  involves  the  entire  or  partial  removal  of  the  uterus.  Demarquay 
agreed  with  Boinet. 

•  On  the  other  hand,  Richet  cautioned  the  Academy  against  pro- 
nouncing any  summary  condemnation  of  an  operation  which  at  present 
is  dreaded  as  ovariotomy  once  was. 

In  conclusion  it  may  be  stated  that  the  question  will  be  decided, 
like  ovariotomy,  by  experience ;  but  to  acquire  that  experience  justifi- 
ably, extreme  caution,  judgment,  and  conscientiousness,  as  well  as  sur- 
gical skill,  are  required. 


CHAPTEE  XLVIII. 
POLYPUS  UTEEI. 

DEFINITION;  FOEMS  OF:  FIBROID  OR  MYOMA;  GLANDULAR  OR 
MUCOUS;  HYPERTROPHIC;  VASCULAR;  PLACENTAL ;  FIBRIN- 
OUS; HISTORY  OF  FIBROID;  FIBRO-CYSTIC  VARIETY;  SYMP- 
TOMS; TERMINATIONS;  INTRA-UTERINE  AND  EXTRA-UTERINE 
POLYPI;  DIAGNOSIS;  TREATMENT;  SLOW  STRANGULATION, 
DANGERS  OF;  TORSION,  CRUSHING,  AND  EXCISION  BY  SCIS- 
SORS; REMOVAL  BY  POLYPTOME,  ECRASEUR,  GALVANIC  WIRE- 
CAUTERY. 

Under  the  name  of  polypus  are  included  all  tumors,  stalked  or  ses- 
sile, which  hang  from  the  inner  wall  of  the  uterus  or  vagina.  It  is, 
however,  convenient  to  exclude  cancerous  growths  and  the  cauliflower 
excrescence. 

The  history  of  the  polypus  of  the  uterus  naturally  follows  upon  that 
of  tumor.  In  the  greater  number  of  cases  of  clinical  interest,  a  poly- 
pus is  nothing  more  than  a  tumor  in  one  of  its  ulterior  stages.  We 
have  seen  that  the  fibroid  tumor  is  liable  to  be  extruded  from  the  wall 
of  the  uterus  into  the  cavity.  In  this  process  of  extrusion,  a  stage 
arrives  when  the  tumor  becomes  first  sessile,  then  pedunculated. 
When  the  main  bulk  of  a  tumor  projects  into  the  uterine  cavity,  its 
seat  of  attachment  being  narrower  than  its  equator,  the  tumor  has  be- 
come a  polypus.  This  definition,  especially  true  of  fibroid  polypus,  is 
generally  true  of  the  other  forms. 

Polypi,  like  ordinary  tumors,  differ  in  their  histological  structure, 
and  in  their  situation  and  other  clinical  characters.  The  source  of  a 
polypus  will  commonly  be  an  indication  of  its  anatomical  character. 


POLYPUS  OF  THE  UTERUS.  677 

This  is  the  consequence  of  the  law  that  like  tissues  produce  like  out- 
growths. For  example,  the  muscular  wall  of  the  body  of  the  uterus 
produces  the  fibroid  or  myomatous  tumor  or  polypus.  The  cavity  of 
the  cervix  and  the  os  uteri  produce  mucous,  glandular,  or  cystic  polypi. 

The  varieties  of  polypi  are  then,  1.  The  fibroid  or  myoma;  2.  The 
glandular  or  mucous ;  3.  The  hypertrophic  polypus  of  the  cervix ;  4. 
The  vascular ;  5.  The  placental ;  6.  The  fibrinous. 

The  form  which  most  frequently  comes  under  clinical  notice  is  the 
fibroid  or  myoma.  The  structure  and  history  of  this  form  are  described 
in  the  preceding  chapter  on  tumors  of  the  uterus.  It  is  only  necessary 
here  to  trace  those  clinical  features  which  are  peculiar  to  the  polypoid 
character.  It  mostly  springs  from  some  part  of  the  wall  of  the  body 
of  the  uterus,  generally  from  the  fundus.  Projecting  into  the  cavity 
of  the  uterus  and  preserving  organic  connection  Avith  this  organ,  it  acts 
in  two  ways — 1st,  it  irritates  as  a  foreign  body  ;  2d,  it  stimulates  uterine 
growth  like  an  ovum.  It  is  a  parasitic  body.  It  is  upon  these  two 
conditions  that  most  of  the  accidents  attending  polypus  depend.  The 
uterus  struggles  to  cast  out  the  unwelcome  guest.  Hence  spasmodic 
pains,  which  are  exponent  of  the  uterine  contractions.  Hemorrhage 
and  leucorrhoeal  discharges  occur  as  the  exponent  of  the  increased 
vascularity  and  development  of  the  uterus. 

Just  as  we  have  fibro-cystic  tumors  of  the  uterus,  so  we  may  have 
fibro-cystic  polypi.  The  softer  myomatous  tumor  which  is  more  con- 
tinuous with  the  proper  muscular  wall  of  the  uterus  may  also  become 
polypoid. 

Fig.  148  is  a  good  illustration  of  a  fibroid  intra-uterine  polypus. 

Fig.  149  is  a  good  illustration  of  a  stalked  polypus. 

Sometimes  instead  of  forming  a  pedicle,  the  tumor  is  cast  out  entire. 

In  the  process  of  extrusion  a  pedicle  is  formed  which  is  sometimes 
capable  of  elongation,  permitting  the  tumor  to  descend  lower  and  lower. 
The  thin  layer  of  proper  uterine  tissue  which  forms  the  shell  stretches 
out,  and  through  the  stalk,  the  vascular  connection  with  the  uterus  is 
maintained ;  at  the  same  time  the  connection  is  further  aided  by  the 
investing  mucous  membrane.  At  other  times  the  connection  is  more 
intimate ;  the  fibroid  structure  of  the  tumor  is  extended  into  the  sub- 
stance of  the  uterus,  forming  a  dense,  short,  thick,  unyielding  stalk. 
Under  uterine  action,  since  the  tumors  will  not  separate,  and  the  stalk 
will  not  lengthen,  the  uterus  itself  is  dragged  down,  producing  partial 
or  complete  procidentia  of  tumor,  and  vagina,  and  uterus.  Such  a  case 
simulating  inversion  of  the  uterus  is  figured  in  Obstetr.  Trans.,  vol.  iii, 
by  the  writer.  It  was  only  after  considerable  trouble  that  the  os  uteri 
"was  found,  when  a  sound  being  passed  up  into  the  uterus,  this  organ 
was  distinguished  from  the  tumor. 

Occasionally,  polypus  produces  actual  inversion  of  the  uterus.  Ex- 
amples of  this  accident  are  referred  to  in  the  Chapter  on  ^'  Inversion." 

In  some  instances  the  stalk  is  so  drawn  out  whilst  the  attachment  is 
at  the  fundus  uteri,  the  tumor  is  quite  outside  the  vulva,  occluding 
the  entrance. 

The  symptoms  differ  in  the  cases  of  polypus  still  retained  within  the 
cavity  of  the  womb,  and  of  polypus  which  has  escaped  through  the  os 


678 


POLYPUS    OF    THE    UTERUS. 


uteri  into  the  vagina.     In  the  latter  case  we  have  the  advantage  of 
digital  examination  to  aid  the  subjective  symptoms.     When  the  tumor 


Fig.  148. 


Fibroid  polyijiis  filling  the  cavity  of  the  uterus.    (Ad  nat.,  Coll.  of  Surgeons,  No.  2666.) 
In  this  case  the  wall  of  the  uterus  is  much  thinner  where  the  tumor  is  attached. 

Fig.  149. 


Fibroid  polypus  which  has  been  extruded  from  the  cavity  of  the  uterus,  the  triangular  shape  of 

which  it  retains.    (Half-size,  College  of  Surgeons.) 

It  is  attached  by  a  long  stalk,  the  root  of  which  is  traced  into  the  wall  of  the  uterus. 

is  locked  up  in  the  uterine  cavity,  we  may  have  to  depend  upon  the 
subjective  symptoms  alone.    The  general  symptoms  are  these :   1.  Hem- 


POLYPUS    OF    THE    UTERUS. 


679 


orrhage,  generally  at  first  in  the  form  of  menorrhagia,  afterwards  liable 
to  recur  at  any  time.  This  is  very  common,  but  not  constant.  2.  Leu- 
corrhoea  of  a  mucous,  purulent,  or  serous  character ;  at  times  tinged 
with  blood,  and  very  offensive,  owing  to  the  discharges  being  retained 
in  the  vagina  and  decomposing  there.     3.  Bearing-down,  or  expulsive 


Fig.  150. 


Fibroid  polypus  moulded  to  shape  of  uteriue  cavity.     (Ad  uat.,  College  of  Surgeons,  No.  2679.) 

pains.  4.  Abrasion,  ulceration,  bleeding  of  the  margin  of  the  os  uteri, 
or  of  the  vagina  from  friction  of  the  polypus.  Similar  conditions  have 
been  noticed  inside  the  uterus,  when  the  polypus  has  been  intra-uterine. 
All  this  irritation  commonly  disappears  when  the  tumor  is  removed. 
5.  Even  more  serious  injury  may  be  caused,  as  in  the  following  case. 
Larcher  describes  a  case'  of  spontaneous  rupture  of  the  uterus  with 

1  Arch.  G^n  de  Med.,  Nov.  1867. 


680  POLYPUS    OF    THE    UTEEUS. 

intra-uterine  polypus.  A  woman  was  adniitted  into  the  Hotel- Dieu, 
with  pain  in  the  abdomen.  After  four  days  profuse  bleeding  set  in. 
She  refused  examination.  Two  days  later  meteorism  and  peritonitis 
appeared,  and  she  died.  Section  revealed  diffuse  peritonitis  and  adhe- 
sion of  all  the  organs  of  the  small  pelvis.  A  polypus  was  found  in  the 
uterus,  seated  in  the  anterior  wall  near  the  isthmus.  The  opposite  side 
of  the  uterus  was  ulcerated,  and  at  one  spot  torn  through,  communi- 
cating with  the  cavity  of  the  abdomen.  6.  They  may  cause  metritis, 
and  septicsemia.  7.  Perhaps  some  distress  in  micturition  or  irritability 
of  the  bladder;  and  in  some  cases,  Avhen  the  tumor  has  been  very 
large,  so  as  to  compress  the  bladder  and  rectum  against  the  walls  of 
the  pelvis,  symptoms  like  those  of  retroversion  of  the  gravid  womb 
have  been  developed,  as  retention  of  urine,  urin?emia,  and  intense  pelvic 
pain.  Gangrene  and  sloughing  of  the  vagina  have  even  been  known. 
8.  When  hemorrhage  and  leucorrhoea  have  continued  some  time,  the 
phenomena  of  anaemia,  blood  degradation,  impairment  of  digestion, 
and  disordered  nutrition  follow.  The  aspect  may  become  sallow;  the 
patient  emaciated  ;  and  the  discharges  offensive.  These,  together  with 
pain,  constitute  a  series  of  symptoms  that  have  often  given  rise  to  the 
conclusion  that  the  disease  M^as  cancer.  In  the  case  of  intra-uterine 
polypus,  all  the  foregoing  symptoms  may  be  present ;  but  in  addition 
there  will  commonly  be  enlargement  of  the  body  of  the  uterus,  and  ex- 
pulsive pains  of  a  spasmodic  character,  constituting  uterine  colic. 

Another  not  uncommon  symptom  is  vomiting.  This  appears  to  be 
due  to  distension  of  the  uterine  fibre.  It  especially  characterizes  the 
intra-uterine  polypus. 

What  has  been  said  of  the  vascularity  of  fibroid  tumors  and  of  the 
source  of  the  hemorrhage,  applies  to  the  fibroid  polypus.  This  is  rarely 
very  vascular  in  its  substance.  But  the  investing  mucous  membrane 
is  commonly  very  vascular.  A  network,  chiefly  of  veins,  is  formed  in 
it,  from  which  blood  easily  oozes  iu  profusion  at  the  menstrual  periods, 
and  under  injury  to  the  surface. 

Occasionally,  however,  vessels  of  considerable  size  have  been  seen 
penetrating  the  substance  of  fibroid  polypi.  The  growth  of  fibroid 
polypi,  like  that  of  fibroids  still  imbedded  in  the  uterine  wall,  is  stim- 
ulated by  the  ovarian  or  menstrual  nisus,  and  still  more  actively  by 
pregnancy,  obeying  the  same  impulse  as  that  which  governs  the  cognate 
muscular  tissue.  In  like  manner  they  are  disposed  to  undergo  a  similar 
retrogression  or  decline  when  pregnancy  has  passed,  and  even  atrophy 
or  calcareous  degeneration  when  the  period  of  menstrual  life  has  ended. 
Hence  the  bony  or  stony  polypi  of  Gerdy.^ 

But  this  post-climacteric  retrogression  is  not  constant.  The  tumors 
may  even  continue  to  grow. 

As  to  the  consequences  of  polypi  much  variety  is  observed.  Vel- 
peau  (Journ.  de  Med.  et  de  Chir.  Prat.,  1859)  says  they  are  sometimes 
harmless,  and  that  the  consequences  are  not  in  relation  with  their  vol- 
ume. Some  disappear  spontaneously.  They  may  be  found  loose,  or 
may  drop  off  unperceived.     But  commonly  repeated  hemorrhages  in- 

1  "  Des  Polypes,  et  de  leur  Traitoment."     Paris,  1833. 


TERMINATIONS.  681 

duce  such  a  degree  of  ansemia,  that  even  death  follows  if  the  tumor  be 
Dot  removed.  And  this  danger  is  greatly  increased  if  pregnancy  super- 
vene. (See  fatal  cases,  in  Gooch,  p.  145.)  Dr.  Cockle  relates  (Med. 
Times  and  Gaz.,  1863)  a  case  of  a  large,  pedunculated,  fibrous  polypus 
attached  near  the  fundus  uteri,  distending  the  uterus  and  vagina,  and 
giving  rise  to  frequent  bleedings  and  offensive  discharges.  The  patient 
died  after  symptoms  of  peritonitis  from  perforation.  The  ovarian 
extremity  of  the  right  Fallopian  tube  was  found  distended  by  the  dis- 
charge, some  of  which  had  escaped  into  the  abdominal  cavity.  Many 
patients  have  died  exhausted  by  bleeding  caused  by  an  intra-uterine 
polypus  not  suspected  during  life.  The  following  case^  is  an  instruc- 
tive example : 

Dr.  Ramskill  was  called  to  see  a  young  woman  who  was  suffering 
from  uterine  hemorrhage.  The  patient  was  twenty-six  years  of  age ; 
she  began  to  menstruate  at  the  age  of  fourteen,  and  this  function  was 
performed  very  regularly  until  her  marriage,  eight  months  ago.  From 
that  time  she  had  suffered  almost  perpetual  hemorrhage.  A  month 
ago,  the  flooding  was  so  profuse  that  it  was  thought  she  had  miscarried. 
Since  then  there  have  been  slight  occasional  intermissions,  but  her 
health  was  deeply  impaired.  When  Dr.  Ramskill  was  called  the  hem- 
orrhage had  returned.  He  observed  strong  bearing-down,  expulsive 
efforts.  The  patient  died  the  same  night  in  convulsions,  evidently 
from  loss  of  blood.  The  body  was  examined  by  Dr.  Ramskill  on  the 
following  day.  The  organs  were  all  healthy.  There  was  no  abdominal 
inflammation.  The  os  uteri  was  healthy,  but  flaccid;  it  was  filled 
with  a  fresh  clot.  There  was  also  blood  in  the  cavity  of  the  uterus. 
The  larger  portion  of  the  uterus,  with  a  body  adhering  to  the  inner 
Avail,  was  forwarded  to  me  by  Dr.  Ramskill.  I  subjected  the  parts  to  a 
careful  examination.  The  walls  of  the  uterus  were  dense,  pale,  somewhat 
thicker  than  natual,  and  the  Avhole  size  of  the  organ  somewhat  larger 
tlian  the  normal  unimpregnated  Avomb.  There  was  no  tumor  or  other 
abnormal  condition  of  the  muscular  Avail,  but  attached  to  the  inner  sur- 
face near  the  fundus,  and  altogether  inclosed  Avithin  the  cavity  of  the 
uterus,  Avas  a  tumor  of  the  size  of  a  small  Avalnut.  The  tumor  did  not 
reach  to  the  uterine  neck.  The  mucous  membrane  of  the  cavity  was 
stretched  over  it.  It  Avas  connected  by  a  broad  basis  to  the  uterus,  but 
would  have  admitted  of  isolation  by  ligature.  The  apex,  or  most  pro- 
jecting part,  had  undergone  partial  disintegration  ;  it  AA'^as  a  little  broken 
up,  softened,  and  had  evidently  quite  recently  been  the  source  of  hemor- 
rhage. Examined  by  the  aid  of  the  microscope,  the  substance  Avas  found 
to  consist  of  nucleated  fibres,  the  nuclei  being  large  and  distinct.  Por- 
tions, especially  those  taken  from  near  the  apex,  exhibited  abundance 
of  oily  globules  and  numerous  blood-globules.  The  structure  of  the 
tumor  differed  from  that  of  the  uterine  wall  in  this  respect  only,  that 
the  fibres  in  the  latter  were  longer,  narrower,  and  more  densely  inter- 
woven, and  the  nuclei  less  distinct.  There  was  no  evidence  of  fatty 
degeneration  in  the  fibres  of  the  uterine  Avail.  There  was  no  doubt 
greater  developmental  activity  in  the  tumor  than  in  the  uterus. 

1  On  "  Uterine  Polypus."     By  Robert  Barnes,  M.D.     Lancet,  1854, 


682  POLYPUS  OF  THE  UTERUS. 

The  practical  deductions  from  this  case  are  of  the  highest  interest 
and  importance : 

1.  The  condition  of  the  uterine  muscular  walls  leads  me  to  conclude 
that  the  conjecture  that  the  patient  had  aborted  a  month  before  her 
death  was  erroneous. 

2.  The  comparative  indolence  of  the  tumor,  and  the  absence  of  any 
remarkable  amount  of  hemorrhage  up  to  the  period  of  marriage,  and 
the  constant  floodings  following  immediately  upon  that  event  and  con- 
tinuing until  the  death  of  the  patient  eight  months  afterwards,  forcibly 
illustrate  the  influence  of  ovarian  and  uterine  stimulation  in  develop- 
ing the  growth  of  uterine  polypi. 

3.  The  case  is  peculiarly  one  of  that  class  to  which  I  have  pointed 
as  strongly  indicating  the  necessity  of  exploration  beyond  the  os  uteri. 

When  pregnancy  supervenes,  the  presence  of  the  polypus  is  a  source 
of  serious  danger.  The  tumor  partakes  of  the  general  development  and 
increased  vascularity  of  the  uterine  wall.  In  this  state  injury  inflicted 
upon  it  is  more  severe  in  its  consequences ;  inflammation  and  necrosis, 
for  example,  are  more  liable  to  follow.  To  anticipate  the  spread  of 
morbid  processes  from  the  tumor  to  the  uterus,  it  is  best  to  remove  the 
tumor  by  the  wire  ecraseur  as  soon  as  its  presence  is  discovered  after 
the  labor.  The  history  of  this  complication  is  pursued  more  fully  in 
my  "  Obstetric  Operations."  Our  business  here  is  more  especially  Avith 
the  non-pregnant  uterus.  It  is,  however,  desirable  to  call  to  mind  that 
polypus  is  likely  to  be  a  cause  of  abortion. 

Generally,  however,  polypi  prevent  pregnancy.  A  curious  case 
occurred  to  the  writer,  of  a  uterus  removed  in  the  dissecting-room,  in 
which  a  polypus  the  size  of  a  filbert  grew  at  the  orifice  of  each  Fal- 
lopian tube,  both  being  completely  closed.  In  another  case  the  tumor 
had  been  driven  outside  the  vulva,  quite  closing  the  entrance  to  the 
vag-^ina.  And  in  the  common  case  of  the  polypus  filling  the  vagina, 
sterility  almost  necessarily  follows. 

A  point  of  great  importance  in  the  constitution  of  fibroid  polypi  is 
noticed  by  E,.  Ferguson  (Introduction  to  New  Sydenham  Soc,  ed,  of 
Gooch),  which  is,  "that  injury  to  this  structure  is  rapidly  followed  by 
a  form  of  decay  like  that  which  is  seen  in  vegetable  matter.  Never- 
theless," he  continues,  "  inflammation  ending  in  suppuration  has  been 
known  to  take  place  in  the  very  heart  of  these  growths.  Their  centres 
are  also  the  occasional  seats  of  softening,  of  effusion  of  blood,  and  of 
cysts." 

The  glandular  or  mucous  polypus  generally  grows  from  the  os  uteri, 
varying  in  size  from  a  filbert  to  a  walnut.  It  is  smooth  and  vascular, 
and  contains,  in  some  instances,  a  curdy  matter,  or  yellowish  viscid 
fluid,  Herbiniaux  described  this  form.  It  is  not  uncommon.  Paget 
thus  describes  it :  The  mucous  or  Nabothian  cysts  probably  originate 
in  cystic  degeneration  of  the  glands  of  the  mucous  membrane  about 
the  cervix  uteri.  Protruding  either  alone  or  with  polypoid  outgrowths 
of  the  mucous  membrane,  they  are  observed  successively  enlarging, 
then  bursting  and  discharging  their  mucous  contents,  and  then  replaced 
by  others  following  the  same  morbid  course.  Or  instead  of  clusters  of 
such  cysts,  one  alone  of  larger  size  and  simpler  structure  may  be  found. 


GLANDULAR    POLYPUS. 


683 


There  is  a  remarkable  example  in  the  Middlesex  Museum  of  a  cyst 
which  appears  to  have  been  produced  in  this  way.  They  generally 
grow  from  a  broad  basis,  rarely  becoming  stalked. 

An  illustration  of  one  form  of  mucous  polypus  is  seen  in  Fig,  151. 
The  patient  was  subject  to  profuse  hemorrhages  and  leucorrhoea. 

They  often  attend  chronic  metritis,  especially  of  the  cervical  portion. 
They  induce  great  hypersemia,  and  give  rise  to  profuse  bleedings.  Being 
small,  soft,  and  easily  retreating  within  the  os  uteri,  they  readily  escape 
detection  by  touch.  The  speculum  is  necessary  to  reveal  them.  They 
project  as  stalked  little  tumors  on  the  red,  abraded  margin  of  the  os 
uteri,  but  are  occasionally  seen  higher  up  the  cervical  canal.  They 
range  in  size  from  a  quarter  of  an  inch  to  half  an  inch  long,  and  some- 
times they  exceed  this.  On  pressure,  as  in  trying  to  seize  them  with 
a  forceps,  they  easily  break  up.  They  are  the  result  of  a  morbid  con- 
dition of  the  cervix.  They  contain  a  viscid  fluid,  and  therefore  may 
be  identified  with  their  glandular  origin.  But  some  are  really  papil- 
lary outgrowths.     These  latter  are  especially  vascular. 


Fig.  151. 


Mucous  or  glandular  cervical  polypus,  causing  abrasion  or  ulceration  in  its  neighoorhood. 

(Ad  nat.,  R.  B.) 


The  so-called  "channelled"  polypus  of  Oldham  appears  to  be  a 
variety  of  the  glandular  polypus,  although  the  fibro-cystic  tumor  may 
put  on  the  appearance  of  channels. 

Fig.  152,  for  which  I  am  indebted  to  Mr.  Arnott,  shows  the  histo- 
logical characters  of  these  outgrowths.  It  exhibits  the  proliferating 
connective  tissue,  with  imbedded,  winding  gland-ducts,  lined  with  co- 
lumnar epithelium. 

These  mucous  polypi  appear  sometimes  in  the  form  of  cystic  tumor 
of  the  cervix  uteri.  Such  a  case  is  described  in  Path.  Trans.,  vol.  ix, 
by  Spencer  Wells.  It  showed  epithelial  debris  with  oil-globules  and 
compound  granular-cells,  found  in  the  larger  cells ;  glandular  epithe- 
lium lined  the  younger  cysts.  I  have  seen  several  such  cases  ;  one  is 
described  in  my  Memoir  on  "  Uterine  Polypus."  Another  is  described 
by  Mr.  Gray  (Path.  Trans.,  vol.  iv) : 

"  It  was  connected  with  the  lining  membrane  of  the  cervix.  Its 
size  and  form  were  not  unlike  that  of  a  dried  plum,  and  it  was  con- 
nected with  the  lining  membrane  by  an  exceedingly  narrow  pedicle. 


684 


POLYPUS    OF    THE    UTERUS. 


It  was  covered  with  a  thick,  viscid  secretion.  It  consisted  of  a  con- 
geries of  cysts  of  a  size  varying  from  a  fine  point  to  a  horse-bean  ; 
their  walls  were  formed  of  dense  fibrous  tissue,  and  their  cavities  con- 
tained a  thick  viscid  fluid,  similar  to  that  found  on  the  outer  surface. 
The  neck  of  the  tumor  was  composed  of  mucous  and  fibrous  tissues,  a 
continuation  of  those  of  the  neck  of  the  uterus.  The  mucous  mem- 
brane, where  it  was  contained  on  the  surface  of  the  neck  of  the  tumor, 
presented  a  continuation  of  the  same  transverse  and  longitudinal  folds 
found  on  the  mucous  lining  of  the  cervix." 

Fig.  152. 


Section  of  a  "  channelled  "  glandular  polypus,  slightly  diagrammatic.     (H.  Arnott.) 

The  liypertrophiG  polypus  of  the  cervix  uteri.  Although  most  polypi 
may  in  some  respects  be  regarded  as  hypertrophies  of  ordinary  struc- 
tures, there  is  one  form  to  which  the  name  seems  to  me  to  be  more 
especially  applicable.  In  a  memoir^  on  the  hypertrophic  polypus,  I 
have  described  as  frequent  the  outgrowth  of  dense  fibrous  polypi  on 
the  edge  of  the  os  uteri  in  cases  of  prolapsus.  So  frequent  is  this  co- 
incidence that  one  is  natui'ally  led  to  conjecture  either  that  a  common 
cause  produces  both,  or  that  one  entails  the  other.  It  can  hardly  be 
that  polypus  is  the  cause  of  hypertrophy  of  the  cervix,  for  in  the 
majority  of  cases  of  hypertrophy  there  is  no  polypus.  The  truth  ap- 
pears to  be  that  that  excessive  growth  Avhich  results  in  hypertrophy, 
sometimes — in  my  experience,  often — produces  jjolypus  as  well. 

These  polypi  are  generally  small,  sometimes  not  larger  than  a  pea, 


St.  Thomas's  Hospital  Eeports,  1872. 


HYPERTROPHIC    POLYPUS.  685 

sometimes  they  are  as  large  as  a  cherry;  they  may  be  round,  but  are 
occasionally  elongated,  cylindrical,  but  more  or  less  irregular  in  form. 
(See  Fig.  Ill,  p.  544.)  They  easily  escape  detection  by  the  finger; 
hence  it  often  occurs  that  their  existence  is  first  revealed  by  the  specu- 
lum. They  generally  begin  to  form  just  inside  the  ring  of  the  os  uteri, 
and  growing  first  inwards,  the  hypertrophied  os  uteri  conceals  them 
and  protects  them  from  the  touch.  When  they  have  existed  some  little 
time,  have  increased  in  size,  and  have  frequently  caused  hemorrhage, 
they  sometimes  descend  below  the  edge  of  the  os  uteri,  and  may  then 
be  felt  like  a  soft  pea  by  the  finger.  But  before  this  stage  they  can 
often  be  seen  through  the  speculum,  especially  through  a  good  bivalve 
which  makes  the  os  gape  widely  when  applied.  They  are  commonly 
single,  but  it  is  not  infrequent  to  find  two  or  three;  and  some  show  a 
disposition  to  subdivision  or  rather  to  lobulation.  They  entail  the 
common  consequence  of  other  polypi,  namely,  hemorrhage.  It  is  this 
symptom  which  mainly  leads  to  examination  and  their  detection.  Gen- 
erally their  removal  is  followed  by  diminution  or  cessation  of  the  hem- 
orrhage; but  here  the  benefit  of  the  operation  ceases.  The  distress 
which  properly  belongs  to  hypertrophy  continues.  For  this  further 
treatment  is  necessary. 

The  pathological  history  of  those  "hypertrophic  polypi"  may,  I 
think,  be  told  as  follows:  The  first  condition  of  their  existence  is  hyper- 
trophy of  the  cervix  uteri.  This  hypertrophy  we  know  frequently  pur- 
sues a  very  uniform  course  affecting  the  whole  structure  of  the  cervix 
alike;  but  sometimes  one  lip,  and  sometimes  even  a  part  of  one  lip,  is 
more  especially  affected.  Thus  we  sometimes  see  the  anterior  or  the 
posterior  lip  shooting  out  an  inch  or  more  beyond  the  other.  At  other 
times  the  os  uteri  being  lobulated  or  fissured,  as  is  seen  after  labor,  one 
lobe  or  portion  of  a  lip  may  take  on  an  exaggerated  growth,  and  project 
beyond  the  level  of  the  rest  of  the  os.  In  such  a  case,  if  studied  by 
the  light  of  observation  of  more  advanced  or  completed  polypoid  for- 
mation, we  may  see  the  origin  of  the  hypertrophic  polypus.  A  small 
lobe  more  or  less  marked  out  on  the  os  by  a  fissure  or  depression  on 
either  side  continues  to  grow  under  the  same  stimulus  that  determines 
the  general  hypertrophy  of  the  cervix.  It  grows  a  little  more  quickly; 
then,  its  base  being  compressed  by  the  firm  structure  of  the  os  on  either 
side  of  it,  is  squeezed  and  elongated  until  it  assumes  the  characteristic 
polypoid  shape.  All  this,  I  think,  I  have  been  able  to  trace  in  the  suc- 
cessive stages  in  different  cases. 

The  structure  of  these  hypertrophic  polypi  of  the  cervix  uteri  entirely 
accords  with  this  theory  of  their  formation.  It  is  identical  with  that 
of  the  hypertrophied  cervix  from  which  the  polypi  spring.  The  mucous 
membrane  with  which  they  are  covered  presents  exactly  the  same  ele- 
ments as  the  mucous  membrane  of  the  corresponding  part  of  the  cervix 
or  OS  uteri.  If  they  are  attached  within  the  cervix,  we  find  columnar 
and  ciliated  epithelium-cells.  If  they  are  attached  to  the  outer  edge  of 
the  os,  then  we  find  chiefly  large  squamous  epithelium-cells.  The  in- 
terior in  both  cases  is  composed  of  bands  of  smooth  fibres  like  those  of 
the  unimpregnated  uterus. 

In  November  last  I  removed  by  galvano-cautery  a  hypertrophied 


686  POLYPUS  OF  THE  UTERUS. 

lip  of  an  OS  uteri,  and  received  from  Dr.  John  Harley  the  following 
report  of  its  constitution  :  "  It  contained  one  or  two  little  cysts,  natural 
follicles  enlarged,  full  of  glairy  mucus  consisting  of  normal  mucus- 
corpuscles.  The  mass  was  composed  of  the  usual  uterine  structures, 
that  is,  interlacing  bands  of  smoother  fibres." 

These  facts  I  had  often  observed  myself,  but  was  glad  to  find  them 
verified  by  my  colleague. 

Whilst  still  attached  to  the  cervix  uteri,  they  are  usually  vivid  red, 
having  a  very  vascular  appearance.  This  is  owing  to  the  mucous 
membrane  investing  them  being  full  of  blood,  deeply  congested,  like 
the  cervix  itself.  When  the  tumor  is  removed  the  surface  often  becomes 
quite  pale. 

The  vascular  polypus  takes  its  rise  from  a  dilatation  or  varicosity  of 
the  vessels  running  under  the  mucous  membrane.  All  these  three 
forms  are  found  in  the  cervix  or  os  uteri.  Among  conditions  simula- 
ting polypus  may  be  mentioned  a  mushroom-like  hypertrophy  of  the 
OS  uteri.  It  is  referred  to  by  Dance,  Berard,  Cruveilhier,  Mayer, 
Meissner,  Malgaigne,  and  Montgomery.  Malignant  growths  of  the  os 
also  often  resemble  polypus  by  their  form. 

In  addition  to  the  above  recognized  forms,  Rokitansky,  Kiwisch, 
Scanzoni,  and  C.  Braun  have  described  other  varieties.  C.  Braun 
(1851)  describes  the  jjlacental  jioly pus.  This  results  from  the  remains 
of  the  placenta  consisting  of  hypertrophied  decidua,  which,  projecting 
into  the  uterine  cavity,  forms  a  polypoid  mass.  Braun  relates  five 
cases  in  which  violent  hemorrhage  broke  out  some  time  after  delivery. 
Polypi  of  the  kind  described  were  found.  In  four  cases  they  were  ex- 
tracted with  the  finger ;  in  one  the  polypus  separated  spontaneously. 
The  fongosites  intra-uterines  of  Nonat,  according  to  Stadtfeld  of  Copen- 
hagen (Dubl.  Q.  Journ.  of  Med.,  1863)  are  placental  remains.  Such 
a  case  was  sent  to  the  writer  by  Dr.  Woodman.  Arthur  Farre  (Todd's 
Cyclop,  of  Anat.)  says  he  has  satisfied  himself  of  the  correctness  of 
Heschl's  opinion,  which  agrees  with  the  above,  upon  the  formation  of 
the  placental  polypus. 

Malgaigne  describes  "  multiform  polypi "  containing  hair. 

Kiwisch  describes  ^.6rmoMS  polypi.  This  author  says  when  menstrua- 
tion has  been  retarded  six  weeks,  fibrinous  polypi  may  arise  from  long 
persistent  hemorrhage,  a  kind  of  apoplexy  of  the  uterus,  a  large  coagu- 
lum  forming  the  upper  part  consisting  mostly  of  fibrin  and  adhering 
by  a  stalk  to  the  uterine  wall,  whilst  the  lower  part  consists  of  red  soft 
coagulum  having  a  coat  of  firm  fibrin.  These  polypi  always  occasion 
profuse  metrorrhagia.  Scanzoni,  however,  does  not  admit  this  view. 
He  contends  that  these  are  cases  of  abortion.  An  ovum  after  fixing 
itself  in  the  mucous  membrane  of  the  uterus,  and  after  being  quite 
clothed  Avith  a  decidua  reflexa,  is  soon  driven  down  by  uterine  contrac- 
tion into  the  cervical  canal,  its  attachments  lengthening  into  a  stalk  by 
the  stretching  and  growth  of  their  tissues.  The  embryo  escapes,  whilst 
a  portion  of  the  membranes  or  stalk  remains,  and  by  accretions  of  fibrin- 
coagula  forms  the  basis  of  fibrinous  polypus.  McClintock  gives  an 
excellent  illustration  of  a  dense  coagulum  simulating  a  fibrinous  polypus. 

I  have  little  doubt  as  to  the  o;eneral  correctness  of  Scanzoni's  criticism. 


DIAGNOSIS.  ,  687 

There  is  a  preparation  in  St.  George's  Museum,  described  by  Dr.  Ogle 
(Pathol.  Trans.,  vol.  xi)  as  a  "large  mass  within  the  uterus,  supposed 
to  be  a  fibrous  tumor,  but  which  proved  to  be  formed  by  retained 
placenta  and  foetal  membranes.  A  woman  died  after  an  operation  for 
femoral  hernia.  On  removing  the  uterus  a  quantity  of  dark  semi- 
coagulated  blood,  along  with  some  shreddy  tough  material,  M^as  found 
protruding  from  its  orifice.  A  firm  substance  was  found  filling  the 
cavity  of  the  uterus.  Excepting  at  its  upper  part,  where  it  was  as  it 
were  continuous  with  the  muscidar  structure  of  the  uterus,  its  whole 
extent  was  free.  It  consisted  of  placenta.  No  foetal  growth  was 
discovered.  But  it  was  evident  that  the  growth  had  been  retained  a 
long  time." 

The  diagnosis  of  a  polypus  which  has  emerged  from  the  cavity  of  the 
uterus  is  usually  not  difficult.  The  sources  of  fallacy  are  chiefly  pro- 
lapsus of  the  uterus,  and  inversion.  Confusion  is  only  possible  when 
the  tumor  resembles  in  size  that  of  the  uterus  in  one  or  other  of  these 
states.  A  tumor  not  bigger  than  a  walnut  can  hardly  be  mistaken  for 
the  uterus.  A  tumor  bigger  than  an  orange  is  not  likely  to  be  the 
uterus.  But  tumors  ranging  between  these  sizes  may  give  rise  to  error. 
The  great  landmark  is  the  os  uteri.  In  prolapsus  this  can  always  be 
found  at  the  lowest  part  of  the  tumor.  By  passing  the  sound  through 
the  OS  we  shall  rarely  fail  to  take  exact  measure  of  the  uterus.  Again, 
the  sensation  conveyed  to  the  touch  by  feeling  the  body  of  the  uterus 
through  its  coat  of  inverted  vagina,  which  can  be  made^o  glide  over 
the  solid  mass  within,  is  very  different  from  a  solid  polypus  felt  directly 
without  any  intervening  coat.  The  uterus  moreover  is  sensitive  to 
compression,  whilst  a  polypus  is  not. 

Complete  inversion  is  distinguished  by — 1,  the  absence  of  an  os  uteri 
at  the  lowest  part;  2,  by  the  neck  of  the  tumor  being  continuous  with 
the  roof  of  the  vagina  which  is  directly  reflected  off  from  it ;  3,  by 
determining  the  absence  of  the  body  of  the  uterus  from  its  normal  po- 
sition by  the  combined  rectal  and  abdominal  touch,  and  the  other  diag- 
nostic manoeuvres  described  and  illustrated  in  the  chapter  on  "  Inver- 
sion." 

Partial  inversion,  namely,  where  the  fundus  of  the  uterus  only 
comes  through  the  os  uteri,  is  more  likely  to  lead  to  error.  In  this 
case,  as  in  polypus,  there  is  a  rounded  tumor  encircled  by  a  ring,  per- 
mitting a  sound  or  the  finger  to  pass  up  betM'een.  See  Figs.  134,  135, 
pp.  616,  617.  The  following  tests  will  commonly  distinguish  the 
partial  inversion.  The  sound  will  not  run  more  than  an  inch,  perhaps 
less,  beyond  the  margin  of  the  encircling  ring,  whereas  in  the  case  of 
polypus  it  will  generally  run  at  one  part  or  another  at  least  two  and  a 
half  inches.  And  the  manoeuvres  which  define  complete  inversion  are 
almost  equally  conclusive  in  the  case  of  partial  inversion.  For  ex- 
ample, the  cup-  or  funnel-like  depression  of  the  fundus  uteri  may  be 
felt  through  the  abdominal  wall. 

Polypi  which  have  been  detected  at  one  time  by  touch  and  even  by 
sight,  may  escape  observation  at  another.  It  is  possible  that  the 
polypi  may  have  become  detached  and  expelled.  But  more  often  this 
intermittent  appearance  is  due  to  the  greater  relaxation  of  the  cervix, 


688  .     POLYPUS    OF    THE    UTERUS. 

and  some  contractile  action  of  the  uterus  attending  hemorrhage  or 
menstruation.  Under  these  conditions  the  tumor  projects  through  the 
open  OS ;  and  retreats  when  these  conditions  subside.  Commonly 
polypi  are  detected,  and  their  size  and  attachment  best  made  out  by  the 
touch.  But  I  have  now  and  then  discovered  glandular  polypi  by  the 
speculum  which  had  escaped  detection  by  the  finger.  A  good  bivalve 
speculum  which  fairly  parts  the  lips  of  the  os  uteri  will  often  enable 
the  sight  to  explore  further  than  the  touch. 

An  intra-uterine  polypus  may  escape  detection  unless  the  cervix  uteri 
be  sufficiently  dilated  to  admit  the  finger.  But  if  the  rule  I  have  ven- 
tured to  lay  down,  namely,  that  in  all  cases  of  obstinate  uterine  hem- 
orrhage, the  cavity  of  the  uterus  should  be  explored  by  dilating  the 
cervix,  be  observed,  we  shall  a,lways  be  able  to  determine  the  presence 
or  absence  of  a  polypus.  And  whether  the  hemorrhage  be  due  to  a 
fibroid  polypus,  to  malignant  disease,  endometritis  or  other  cause,  not 
only  is  accurate  diagnosis  arrived  at,  but  the  way  is  opened  for  the 
most  efficient  treatment.  It  has  been  noticed  that  the  hemorrhage  is 
generally  more  profuse  when  the  polypus  is  intra-uterine. 

It  is  curious  to  notice  how  deceptive  is  the  sensation  communicated 
to  the  touch  by  some  fibroid  polypi.  Even  under  palpation  after  re- 
moval they  may  give  the  impression  of  fluctuation,  as  if  they  were 
cystic  and  contained  fluid,  whereas  on  section  they  are  found  quite 
homogeneous. 

A  very  important  practical  rule  is,  in  a  case  of  presumed  polypus, 
to  trace  up  the  tumor  to  its  attachment  before  operating.  This  can 
generally  be  accomplished  by  finger  or  sound.  If  the  finger  can  find 
room  to  pass  along  the  tumor  to  its  insertion,  then  by  combined  ab- 
dominal palpation  we  may  get  the  body  of  the  uterus  above  the  tumor 
between  the  two  hands.  The  information  so  obtained  is  unequivocal. 
Where  the  finger  cannot  reach,  the  sound  will  answer  nearly  as  well. 
We  feel  the  fundus  of  the  uterus  supported  on  the  sound  through  the 
abdominal  wall,  whilst  a  finger  in  the  vagina  distinguishes  the  tumor. 

Were  these  methods  of  diagnosis  rigorously  carried  out,  error  would 
be  almost  impossible.  But  polypus  is  so  common,  and  inversion  so  rare, 
that  the  mind  is  taken  possession  of  by  the  more  common  event.  The 
rarer  event  not  being  contemplated,  we  readily  accept  as  conclusive  in 
favor  of  polypus  evidence  which  is  really  insufficient. 

One  form  of  the  placental  polypus  may  easily  be  mistaken  for  an 
ordinary  polypus.  Thus  I  have  been  called  to  cases  where  the  patient 
was  said  to  be  bleeding  from  polypus,  and  I  have  found  a  mass  more 
or  less  firm  partly  projecting  from  the  os  uteri,  and  attached  to  the 
inner  surface  of  the  body  of  the  uterus.  By  dilating  the  cervix  by 
laminaria-tents,  these  masses  were  sometimes  removed  by  the  finger, 
and  sometimes  by  the  wire-§craseur.  On  examining  the  structure  of 
the  masses  removed,  they  have  been  found  to  be  the  placenta  of 
abortion. 

The  Treatment — A  polypus,  being  a  tumor  in  process  of  spontaneous 
expulsion,  seems  to  invite  surgical  assistance.  We  are  simply  called 
upon  to  complete  a  cure  where  Nature  points  the  way.  The  treatment 
is  generally  successful.     It  constitutes  one  of  the  most  satisfactory  ap- 


TKEATMENT.  689 

plications  of  surgical  skill.  The  principal  methods  resolve  themselves 
into — 1,  removal  by  strangulation  ;  2,  by  torsion  ;  3,  by  various  meth- 
ods of  excision. 

Palliative  or  temporizing  measures  are  rarely  indicated.  If  hemor- 
rhages, leucorrhoea,  forcing  down,  or  other  urgent  local  or  general  dis- 
tress exist,  the  indication  to  remove  the  tumor  is  generally  imperative. 
Even  if  a  polypus  give  rise  to  no  trouble,  it  is  the  wiser  course  to  re- 
move it,  since  it  may  at  any  unexpected  time  be  the  occasion  of  mis- 
chief. 

1.  It  is  convenient  in  the  first  place  to  dispose  of  strangulation. 
Experience  of  its  dangers,  and  the  perfection  to  which  the  proceedings 
for  effecting  immediate  removal  of  polypi  have  been  brought,  have 
fairly  exploded  this  method. 

The  ligature  was  for  a  long  time  applied  so  as  to  effect  strangulation 
and  slow  detachment  by  sloughing.  Levret  contrived  an  instrument 
consisting  of  two  silver  canulse  curved,  and  so  united  by  a  joint  that 
they  are  shaped  like  a  pair  of  forceps.  A  ligature  is  passed  through 
the  tubes,  the  noose  is  applied  round  the  root  of  the  polypus,  and  the 
ends  are  then  drawn  tight,  and  tightened  daily  until  the  tumor  drops. 
Another  instrument  is  described  by  Nissen  (De  Polypis  Uteri.  See 
Richter's  Chir.  Bibl.,  b.  ix,  s.  613).  It  consists  of  two  silver  tubes 
curved  carrying  a  ligature.  The  tubes  are  brought  together  by  a  third 
double  canula,  and  then  the  ends  of  the  ligature  are  tightened.  Gooch's 
well-known  instrument  is  a  modification  of  Nissen's,  the  tubes  being 
made  straight. 

Until  recent  years  this  method  of  slow  strangulation  was  generally 
pursued  in  cases  where  the  polypus  was  large  and  the  pedicle  thick. 
The  strangulation  by  arresting  the  circulation  through  the  pedicle 
gradually  caused  the  tumor  to  fall  off  by  sloughing  or  mortification. 
This  process  would  take  from  two  to  ten  days  or  more  to  be  completed. 
During  this  time,  the  tumor  sloughing,  would  give  rise  to  offensive 
discharges ;  inflammation  has  extended  from  the  pedicle  to  the  sub- 
stance of  the  uterus,  peritonitis  and  death  ensuing.  The  metritis  and 
perimetritis  might  be  induced,  as  stated,  from  simple  extension  from 
the  injury  caused  to  the  neck  of  tli<e  tumor.  But  more  frequently  these 
affections  were  the  result  of  pyaemia  or  septicaemia. 

In  many  instances  death  has  followed  the  attempt  to  remove  the 
tumor  by  Gooch's  instrument.  Dr.  R.  Lee  records  nine  deaths  out  of 
fifty-nine  operations.  Dr.  McClintock  records  three  deaths  out  of  ten 
operations,  the  causes  being  "phlebitis,"  or  metritis  and  peritonitis. 

There  is  serious  danger  from  retaining  for  hours  or  days  consecu- 
tively a  rigid  instrument  projecting  beyond  the  vulva.  Thus,  in  St. 
George's  Museum,  is  a  specimen  (No.  xiv,  54)  showing  that  the  instru- 
ment may  cause  death  by  impalement.  It  is  a  uterus  with  a  fibrous 
polypus  attached  around  which  a  ligature  has  been  applied,  and  which 
is  seen  in  situ.  The  operation  was  effected  by  means  of  a  canula.  The 
patient  having  turned  in  bed  on  her  back,  the  canula  pressing  on  the 
mattress,  perforated  the  uterus,  and  caused  death. 

In  the  following  cases  death  ensued  in  other  ways  :  St.  George's 
Museum  (No.  xiv,  50).     Close  to  the  os  uteri  is  a  fibrous  polypus,  to 

44 


690  POLYPUS  OF  THE  UTERUS. 

the  pedicle  of  which  a  ligature  was  applied.    The  patient  died  of  peri- 
tonitis six  days  after  operation. 

The  two  following  specimens  are  in  the  same  museum : 

No.  xiv,  55.  A  large  polypoid  tumor  removed  by  ligature.  Death 
ensued  from  peritonitis  a  week  after  operation. 

No.  xiv,  58.  Uterus  with  a  polypus  growing  from  its  wall,  which 
has  been  partly  separated  by  the  ligature.  The  patient  died  of  peri- 
tonitis three  days  after  operation. 

St.  Bartholomew's  Museum  shows  the  following  instructive  cases : 

Ser.  xxxii,  49.  A  uterus  with  many  fibrous  tumors ;  one  suspended 
by  narrow  pedicle  from  anterior  wall  just  within  the  internal  cervix 
(os?)  pendulous  beyond  the  os  uteri,  softened  and  changed  in  conse- 
quence of  its  pedicle  having  been  tied  shortly  before  death.  Patient, 
set.  forty,  had  suffered  menorrhagia  for  two  or  three  years.  Pedicle 
tied  by  a  double  canula ;  next  day  dysuria,  then  retention  of  urine, 
then  signs  of  peritonitis  ;  death  on  third  day. 

No.  32.3.  Section  of  a  uterus  and  firm  fibrous  polypus,  which  has 
grown  from  nearly  the  whole  circumference  of  its  neck.  A  ligature 
was  placed  around  the  polypus  near  the  line  of  its  connection  with 
the  uterus ;  but  the  death  of  the  woman  took  place  before  the  liga- 
ture had  separated.  A  portion  of  glass  occupies  the  groove  in  which 
the  ligature  was  tied ;  and  it  will  be  observed  that  this  groove,  in  a 
part  of  its  extent,  is  formed  in  the  substance  of  the  uterus,  the  neck  of 
which  is  elongated  and  almost  imbedded  in  the  upper  part  of  the 
polypus. 

No.  32.24.  A  uterus  from  which  a  fibrous  polypus  was  removed  by 
ligature  eight  days  before  death.  A  circular  ulcer  about  one-half 
inch  in  diameter  in  the  fundus  of  uterus  marks  the  spot  where  polypus 
has  sloughed.  The  whole  tissue  of  uterus  is  swollen.  From  a  mid- 
dle-aged woman — she  died  with  acute  inflammation  of  the  uterine 
veins.     Fig.  153,  p.  691  is  another  illustration. 

The  danger  of  strangulation  by  ligature  is  indeed  somewhat  lessened 
by  cutting  oif  the  tumor  below  the  seat  of  strangulation.  By  this 
means  we  diminish  the  source  of  decomposition,  and  hence  the  risk  of 
septicaemia.  But  the  strangled  stump  may  still  be  enough  to  set  up 
mischief;  and  the  only  argument  remaining  for  not  removing  the 
whole  tumor  at  once  without  the  intervention  of  the  ligature  is  the 
fear  of  hemorrhage.     Experience  has  dispelled  even  this  fear. 

Phlegmasia  dolens  has  followed  slow  strangulation. 

In  addition  to  the  examples  I  have  cited,  the  literature  of  the  sub- 
ject down  to  twenty  years  ago  may  be  said  to  abound  with  evidence  of 
the  dangers  and  mortality  attending  slow  strangulation. 

2.  Torsion  and  excision  by  scissors  are  especially  applicable  to  small 
polypi  of  the  cervix.  To  carry  out  these  proceedings  it  is  generally 
necessary  to  use  the  speculum.  My  speculum,  Cusco's  or  Marion 
Sims's,  are  the  most  convenient.  Torsion  should  on  no  account  be  used 
if  the  stalk  is  at  all  thick  or  firm.  Montgomery,  says  McClintock, 
published  a  case  where  a  portion  of  the  uterus  w^as  actually  detached, 
and  brought  away  adhering  to  the  pedicle ;  the  woman  nearly  lost  her 


TREATMENT. 


691 


life  from  hemorrhage.  Some  soft  mucous  or  glandular  polypi  are 
cured  by  crushing  with  the  forceps.  Seized  between  the  blades  of  the 
instrument,  it  is  enough  to  break  them  up.  Thus  killed,  the  hemor- 
rhage commonly  ceases.  But  the  spot  may  be  touched  with  per- 
chloride  of  iron  as  a  further  security. 

The  removal  of  polypi  even  of  considerable  size  by  scissors  was  ex- 
tensively practiced  by  Dupuytren,  Siebold,  Mayer,  and  others,  who 


Uterus  with  firm  fibrous  polypus  attached  to  the  upper  wall.    (Half-size,  St.  Bartholomew's,  32,  3a.) 
A  ligature  was  placed  round  the  neck  of  the  polypus  eight  days  before  the  patient's  death.    Fatal 
peritonitis  followed  operation.    The  portion  of  the  polypus  below  the  ligature  is  intensely  congested, 
and  some  of  its  surface  has  sloughed.    The  patient  had  been  much  reduced  by  hemorrhage. 


preferred  it  to  the  ligature.  I  have  seen  it  practiced  by  Lisfranc.  Sir 
Charles  Locock  generally  preferred  it. 

Although  it  may  be  generally  true  that  no  serious  hemorrhage  fol- 
lows excision,  still  the  risk  is  not  to  be  disregarded.  Montgomery 
relates  a  fatal  case.  McClintock  relates  a  case  of  polypus  growing 
from  the  inside  of  the  anterior  lip  of  the  os  uteri  by  a  pedicle  as  thick 
as  one's  third  finger.  There  was  no  perceptible  pulsation  in  the  pedicle. 
He  divided  this  with  a  scissors  close  to  the  tumor.  Smart  hemorrhage 
succeeded,  and  the  saturated  solution  of  perchloride  of  iron  in  glycerin 
was  applied.  This  checked  the  general  oozing,  but  two  arteries  con- 
tinued to  bleed,  and  having  failed  after  repeated  attempts  to  take  them 
up,  he  included  the  pedicle  in  a  strong  silk  ligature,  whereby  the  hem- 
orrhage was  completely  arrested. 

The  actual  cautery  would  in  such  cases  be  applicable. 

Sir  James  Simpson  used  a  polyptome,  which  consists  of  a  knife 
strongly  curved  like  a  reaping-hook,  or  the  obstetric  decapitating  hook 
of  Ramsbotham,  surmounting  a  long  stem. 

Dr.  Aveling  contrived  (Obstetr.  Trans,  and  Catalogue  of  Obstetric 


692 


POLYPUS    OF    THE    UTERUS. 


Instruments,  1866)  a  hook  grooved  on  the  concave  side  to  encircle  the 
stalk,  and  a  sliding  knife  which  is  pushed  up  to  the  groove  by  a  screw, 
of  course  dividing  the  stalk  in  its  progress.     (See  Fig.  154.)     It  is  an 
excellent  instrument,  most  effective  when  the  neck  of 
Fig.  154.  the  poljpus  Can  be  embraced  in  the  hook.     Still  more 

accurate  and  more  effective  is  the  wire-rope  §craseur 
now  generally  preferred.     It  combines  the  advantages 
of  excision  with  those  of  the  ligature.    It  cuts  through 
the  pedicle  at  once.     The  original  of  these  instruments 
is  Professor  Graefe's  apparatus,  specimens  of  which 
are  found  in  the  armamentariaof  raostof  the  London 
hospitals.     Simpson  describes  (Edinb.  Med.  Journ., 
1850)  an  instrument  given  him  by  Dr.  Sabine,  of  New 
York,  by  which  a  silver  wire  was  made  to  cut  through 
the  pedicle  by  a  screw.     Chassaignac's  chain-6craseur 
has  been  used,  but  it  is  not  so  convenient  as  the  wire 
instruments.     The  rope  has  been  made  of  strands  of 
several  fine  iron  or  copper  wires ;  but  of  late  it  has 
been  found  that  a  stout,  single  iron  wire,  made  flexi- 
ble, answers  better.     For  the  best  form  of  the  wire 
^craseur,  see  Fig.  40,  p.  127.    A  loop  is  drawn  through 
the  eye  of  the  stem,  and  by  aid  of  the  stem  and  two 
or  three  fingers  in  the  vagina,  the  pedicle  is  caught. 
The  noose  is  then  tightened  by  a  travelling  screw  or 
windlass,  until  it  comes  back  through  the  eye,  when 
'the  pedicle  is  found  to  be  divided.     The  tumor  is  felt 
rolling  loose  in  the  vagina,  and  may  be  seized  and 
drawn  out  by  a  vulsellum.     If  the  tumor  be  very 
large,  the  extraction  from  the  vagina  may  be  a  work 
of  some  difficulty.     It  has  been  found  necessary  to 
grasp  it  with  the  midwifery  forceps,  and  deliver  it 
like  a  child's  head.     In  noosing  the  pedicle  it  is  not 
necessary  to  carry  the  noose  beyond  the  tumor,  or  up 
to  the  insertion  of  the  root  in  the  uterine  wall.     It  is 
enough  to  get  the  noose  beyond  the  equator  of  the 
tumor,  when  on  drawing  in  the  slack  of  the  wire  be- 
Aveiing's  poiyptrite.     fore  tightening  by  the  screw  or  windlass,  the  noose 
(One-third  nat.  size.)     ^iH  adjust  itsclf  at  the  juuctiou  of  tlic  tumor  with  its 
root.     The  stump  decays,  breaks  up,  and  there  is  no 
probability  of  another  tumor  springing  from  it.     Generally,  when  a 
polypus  is  removed,  the  cure  is  permanent.     But  of  course  a  second 
uterine  fibroid  may  be  converted  into  a  polypus  like  the  first.     Should 
bleeding  occur,  it  may  be  stanched  by  perch] oride  of  iron  carried  on 
lint,  and  maintained  by  plugging. 

Intra-uterine  polypi  may  be  noosed  and  excised  in  like  manner.  If 
necessary,  the  cervix  uteri  can  be  expanded  beforehand  by  laminaria- 
tents,  or  by  incision. 

It  is  not  commonly  necessary  to  use  chloroform  for  this  operation. 
If  the  tumor  be  easily  accessible,  the  wire  noose  can  be  slipped  over  it 
without  causing  much  pain;  and  the  tumor  itself  being  insensitive,  the 


TREATMENT. 


693 


actual  excision  is  painless.  And  in  discussing  the  treatment  of  inver- 
sion, we  have  seen  that  pain  during  the  tightening  of  the  wire  gives 
warning  that  the  tumor  is  not  a  polypus,  thus  giving  opportunity  to 
retrieve  error.  But  when  the  tumor  is  large,  and  the  stalk  difficult  of 
access,  it  will  often  be  best  to  give  chloroform  ;  this  enables  the  opera- 
tor to  pass  his  hand  if  necessary  well  into  the  pelvis,  and  to  explore 


Fig.  155. 


Operation  for  removing  polypus  uteri  by  wire-ecraseur. 
The  polypus  is  seized  and  pulled  down  by  vulsellum,  and  the  wire  is  carried  over  it. 


thoroughly  the  relations  of  the  tumor  before  adjusting  the  wire.  A 
full  diagnosis  being  made,  the  ecraseur,  armed  with  its  wire-loop  of  a 
size  corresponding  to  the  idea  we  have  formed  of  the  size  of  the  tumor, 
is  passed  in  either  in  front  or  behind.  The  end  of  the  instrument  is 
carried  fairly  up  to  the  base  of  the  polypus,  whilst  the  loop  is  slipped 
over  the  polypus  itself  by  help  of  a  finger,  or  a  firm  probe  notched. 
When  the  loop  is  once  over  the  equator  of  the  polypus,  a  few  turns  of 
the  screw  suffice  to  carry  it  down  to  the  stalk.  It  then  adjusts  itself, 
and  the  continued  working  of  the  screw  completes  the  abscission.  In 
some  cases  it  is  convenient  first  to  seize  the  tumor  by  a  vulsellum,  and 
to  draw  it  down  low  in  the  pelvis  before  adjusting  the  wire  as  illus- 
trated in  Fig.  155. 

When  the  base  of  the  polypus  is  very  thick,  and,  especially  if  we 
suspect  that  it  is  unusually  vascular,  the  galvanic  wire  cautery  is  the 
best  instrument  to  use. 

Even  after  an  intra-uterine  polypus  has  been  severed  from  its  attach- 
ment by  the  wire,  it  is  not  always  easy  to  get  it  away.  It  rolls  about 
under  touch  or  attempt  to  seize  it,  like  one  Chinese  ball  inside  another. 
If  on  grasping  it  by  a  vulsellum  it  will  not  come  through  the  cervix 


694  POLYPUS  OF  THE  UTERUS. 

uteri,  it  may  become  necessary  to  cut  it  up,  and  to  bring  it  away  piece- 
meal. This  may  be  done  by  scissors,  or  it  may  be  necessary  to  dilate 
the  cervix  by  laminaria-tents,  or  incision,  or  by  my  bags. 

The  advantages  of  instant  removal  of  polypi  over  slow  strangulation 
are  very  decided.  The  relief  is  speedy ;  no  instrument  is  left  in  the 
parts ;  and  the  risk  of  inflammation  and  septicaemia  is  infinitely  less. 
Nor  are  these  advantages  weakened  by  any  serious  drawbacks.  The 
risk  of  hemorrhage  is  very  small.  If  any  bleeding  occur  it  may  be 
checked  by  touching  the  surface  with  a  solution  of  perchloride  of  iron, 
or  by  plugging.  I  have  only  once  seen  serious  septicaemia  follow  abla- 
tion by  the  wire-ecraseur.  The  patient  recovered.  And  it  may  fairly 
be  said  that  accidents,  such  as  those  of  which  examples  are  given  above 
from  strangulation,  are  of  extreme  rarity  after  instant  excision. 

It  is  pro])er  to  enforce  absolute  rest  in  the  horizontal  posture  for 
some  days  after  the  operation  as  a  security  against  hemorrhage  and  in- 
flammation. But  in  one  case  in  which  I  removed  a  large  polypus  by 
the  wire,  the  subject  travelled  home  more  than  a  hundred  miles  by  rail 
the  same  day  under  the  charge  of  her  medical  attendant  without  any 
untoward  accident.  This  was  done  of  course  under  j^eculiar  and  urgent 
circumstances.     Such  a  risk  ought  not  to  be  incurred. 

The  treatment  of  the  "  hypertrophic  polypi"  to  be  entirely  successful 
must  be  based  upon  the  view  traced  of  their  pathology.  They  must  be 
removed,  as  a  matter  of  course,  but  their  removal  is  not  enough.  The 
simplest  way  of  removing  them  is  to  cut  them  off  with  scissors.  Should 
any  bleeding  follow,  this  may  be  arrested  by  applying  a  small  pledget 
of  lint  soaked  in  perchloride  of  iron,  and  then  plugging  the  vagina  with 
lint  soaked  in  carbolic  acid  oil.  The  risk' of  after-bleeding  then  is  very 
small,  provided  the  precaution  be  taken  to  keep  the  patient  in  bed  for 
two  or  three  days  after  the  operation.  I  may  here  state  incidentally, 
that  there  is  no  operation  on  the  cervix  or  vagina  so  slight,  if  involv- 
ing incision  of  the  mucous  membrane,  that  may  not  be  followed  by 
great,  even  dangerous,  flooding,  if  this  precaution  be  not  rigorously 
enforced.  Hence  it  should  be  recognized  as  a  rule  in  practice,  never 
to  perform  such  operations  in  the  consulting-room  or  in  the  out-pa- 
tients' room  of  a  hospital. 

The  next  indication  after  removal  of  the  polypus  is  to  counteract  the 
process  of  hypertrophic  extension  of  the  cervix  uteri,  of  which  the 
polypus  is  a  consequence.  The  treatment  in  the  advanced  stages  when 
the  elongation  is  considerable,  is  a  subject  not  now  under  discussion. 
I  can  only  here  consider  what  is  to  be  done  in  the  earlier  or  incipient 
stages  of  hypertrophy  when  decided  action  may  effectually  arrest  the 
morbid  process.  For  a  week  or  so  after  the  removal  of  the  polypus 
rest  is  all  that  is  necessary  ;  then  if  any  active  inflammation  of  the 
cervix  remain,  the  occasional  application  of  solid  nitrate  of  silver  or 
sulphate  of  zinc,  with  lead  lotions,  should  be  used  until  the  inflamma- 
tion has  subsided.  This  accomplished,  a  free  slough  of  the  most  hy- 
pertrophied  lip  should  be  wrought  by  applying  potassa  cum  calce,  or 
the  actual  cautery  in  a  line  across  the  lip.  The  healing  of  this  slough 
induces  altered  nutrition  of  the  part,  promotes  absorption,  and  the  con- 
traction following  being  inwards  or  centripetal,  acts  in  direct  antagonism 


TUBERCLE    OF    THE    UTERUS.  695 

to  the  morbid  hypertrophic  extension.  Injections  are  useful  to  deodorize 
the  discharges.  The  best  are  of  lead,  percliloride  of  iron,  creasote,  or 
permanganate  of  potash. 

The  after-treatment  consists  in  rest,  generous  diet,  tonics.  If  there 
is  bleeding,  a  pledget  of  lint  steeped  in  percliloride  of  iron  can  be  ap- 
plied to  the  seat  of  the  stump  through  a  speculum.  The  ulcerations 
caused  on  the  mucous  membrane  of  the  cervix  and  vagina  by  the  chafing 
of  the  tumors  will  often  heal  now  the  cause  is  removed.  If  not,  occa- 
sional touching  with  nitrate  of  silver  will  be  required.  Gooch  very 
properly  insists  that  we  should  not  be  deterred  from  dealing  with  poly- 
poid tumors  under  the  doubt  that  they  may  be  malignant.  If  cancerous 
growths  assume  the  common  mushroom-form  admitting  of  being  em- 
braced by  a  ligature,  even  in  part,  he  has  found  it  good  practice  to 
remove  them.  The  hemorrhages  are  checked,  and,  at  least,  a  respite  is 
gained.  The  accuracy  of  this  view  has  been  lately  confirmed  by  many 
practitioners. 

The  sessile  glandular  polypi  are  easily  removed  by  a  fine  wire- 
ecraseur.  Prominent  Nabothian  glands  or  follicles  are  cured  by  simply 
puncturing  them.  The  vascular  polypi,  if  broadly  sessile,  are  most 
effectually  treated  by  the  actual  cautery,  a  convenient  way  of  applying 
which  is  by  the  galvanic  current. 

Placental  polypi  I  have  several  times  removed  satisfactorily  by  the 
wire-ecraseur.  The  loop  applied  close  at  the  base  shaves  them  off  com- 
pletely, or  at  any  rate  will  so  break  up  their  tissue,  that  hemorrhage 
ceases,  and  the  structure  is  quickly  removed  by  disintegration. 


CHAPTER  XLIX. 

TUBEKCLE  OF  THE  UTERUS. 

Tubercular  disease  of  the  uterus  may  most  fitly  be  considered 
before  cancer.  The  uterus  does  not  seem  to  be  peculiarly  prone  to  this 
disease,  and  when  it  is  so  affected,  other  organs  or  structures  are  almost 
invariably  aifected  at  the  same  time.  The  development  of  tubercle  in 
the  uterus  has  been  especially  observed  to  date  from  labor.  This  cir- 
cumstance suggests  the  hypothesis  that  the  active  physiological  process 
of  gestation  and  labor  augments  the  predisposition  of  the  uterus  to  be- 
come the  seat  of  tubercular  mischief,  and  thus  determines  or  directs 
any  constitutional  tendency  that  may  exist  to  this  organ.     There  are 


696  TUBERCLE    OF    THE    UTEEUS, 

other  facts  which  support  this  hypothesis.  Thus  I  have  often  observed 
that  the  calcareous  degeneration  of  the  placenta,  a  condition  which 
chiefly  affects  the  decidua — a  true  uterine  structure — is  most  liable  to 
occur  in  strumous  or  tubercular  subjects.  When  tuberculosis  appears 
after  childbirth,  it  is  developed  on  the  placental  site. 

This  sequence  of  tubercular  disease  of  the  uterus  upon  labor  is  illus- 
trated in  a  preparation  in  Guy's  Museum  (2261^"*),  taken  from  a  woman 
aged  twenty-four.  She  had  general  peritonitis  of  a  chronic  character 
for  several  weeks,  commencing  after  labor,  from  which  it  M^as  thought 
to  have  proceeded.  It  was  found,  however,  to  be  tubercular.  The 
interior  of  the  uterus  was  filled  with  tuberculous  matter ;  the  cervix 
being  unaffected. 

The  disease  has,  however,  been  observed  in  girls  who  have  never 
been  pregnant.  The  researches  I  have  made  dispose  me  to  conclude 
that  tuberculization  of  the  uterus  is  very  rare  before  puberty. 

Mr.  Hutchinson  exhibited  to  the  Pathological  Society  (Path.  Trans., 
vol.  viii),  a  uterus  of  a  girl  aged  fifteen.  It  was  distended  into  a  cavity 
which  contained  two  drachms  of  fluid  resembling  ill-formed  pus,  only 
more  glairy  and  adhesive.  There  was  no  evidence  of  ulceration  of  the 
mucous  membrane,  nor  any  deposit  in  the  parenchyma  of  the  uterus. 
"  I  was  inclined,"  says  Hutchinson,  "  to  regard  it  as  illustrating  the 
exudation  of  tuberculous  material  on  the  free  surface  of  the  lining 
membrane,  by  which  chronic  inflammation,  ending  in  the  effusion  of 
an  admixture  of  pus,  had  been  caused."  There  was  tubercle  in  liver, 
kidneys,  lungs  ;  and  she  died  of  albuminuria.  Boivin  and  Duges 
figure  (pi.  xvi)  a  specimen  of  tubercle  in  the  right  tube  and  right  broad 
ligament,  taken  from  a  girl  aged  sixteen. 

Tubercle  appears  on  the  mucous  membrane,  and  especially  on  the 
posterior  wall,  in  the  form  of  gray  granulations,  which  gradually  crowd 
together,  and  extend  into  the  Fallopian  tubes,  and  sometimes  into  the 
cervix.  Sooner  or  later,  softening  sets  in.  The  mucous  membrane, 
beset  with  tubercles,  is  changed  to  a  yellow-cheesy  pulpy  layer,  under- 
neath which  the  tuberculization  attacks  the  uterine  parenchyma,  so 
that  at  last  the  uterine  wall  exhibits  a  similar  change  for  a  considerable 
depth.  This  cheesy  mass  suppurates,  and  is  thrown  off  in  lumps  of 
variable  size.  The  discharge  is  sometimes  obstructed  by  closure  of  the 
OS  uteri,  when  it  collects,  distends  the  uterus,  and  forms  hydrometra. 
The  tuberculization  and  suppuration  commonly  are  bounded  by  the  os 
uteri  internum.  They  rarely  overstep  this  spot.  Rarely  also  is  tuber- 
culization primary  in  the  cervix.  When  it  occurs  there,  the  suppura- 
tive process  makes  deep  excavations  in  it. 

Destruction  of  tissue  may  follow  upon  ulceration  ;  and  even  perfora- 
tion may  take  place  through  the  uterine  wall  or  the  Fallopian  tubes, 
leading  to  effusion  into  the  peritoneal  cavity.  The  tissues  of  the  uterus 
may  be  so  disorganized,  that  rupture  may  ensue  if  pregnancy  exist,  as 
in  a  case  related  by  H.  Cooper  (Medical  Gazette,  1860) ;  and  even  in 
the  case  of  the  non-pregnant  uterus,  as  in  an  example  related  by  Guzzo 
(Archives  Gen.  de  Med.,  1848). 

Tubercular  degeneration  of  the  uterus  is  almost  always  attended  by 
a  similar  condition  in  other  organs.     But  in  not  a  few  cases  the  disease 


TUBERCLE    OF    THE    UTEEUS,  697 

seems  concentrated  in  the  uterine  mucous  membrane,  so  that  the  name 
"phthisis  uteri"  might  fairly  be  given  to  it.  When  this  is  the  case, 
ragged  irregular  ulcerations  form  on  its  mucous  surface ;  constant  puru- 
lent discharges,  at  times  streaked  with  blood,  occur.  Some  enlarge- 
ment of  the  organ  is  common.  Severe  jjain  is  a  frequent  symptom. 
The  disease,  as  may  be  supposed,  is  very  intractable. 

Sometimes  the  whole  genital  mucous  tract  is  affected.  The  Fallo- 
pian tubes  are  commonly  implicated.  Indeed,  Rokitansky  and  others 
affirm  that  it  begins  in  the  tubes.  When  the  tubes  are  aifected  they 
become  enlarged,  distended,  tortuous,  forming  elongated  tortuous, 
sausage-like  tumors  on  either  side  of  the  uterus,  resembling  in  shape 
the  tubes  affected  with  dropsy,  but  differing  in  being  more  solid.  This 
condition  of  the  tubes  is  well  seen  in  Fig.  157,  p.  699,  from  Carswell ; 
but  often  the  enlargement  is  considerably  greater. 

The  mucous  membrane  is  not,  however,  always  the  seat  of  election. 
Thus  Dr.  Willoughby  relates  (Pathological  Transactions,  1869)  the 
case  of  a  woman  aged  thirty-five,  the  mother  of  several  children,  who 
had  pulmonary  tubercle,  and  died  of  tubercular  pleurisy  and  peritonitis. 
She  had  not  menstruated  for  years.  The  pelvic  peritoneum  was  beset 
with  cheesy  masses,  one  of  which,  the  size  of  a  walnut,  was  beneath  the 
peritoneum.  This  mass  had  produced  rectangular  anteflexioii  of  the 
uterine  cavity.  The  Fallopian  tubes  were  immensely  distended  with 
the  same  cheesy-looking  substance,  and  curiously  convoluted ;  the  fim- 
briated extremities  were  entirely  obliterated  by  coalescence  with  the 
ovaries.  These  organs  were  as  large  as  walnuts,  filled  with  the  same 
cheesy  material,  and  one  contained  an  effusion  or  heematocele.  No 
tubercular  deposit  was  apparent  in  the  lining  membrane  of  the  uterine 
cavity. 

The  urinary  mucous  tract  is  sometimes  morbid.  Sometimes  all  the 
pelvic  organs  are  matted  togetlier  by  plastic  effusions.  Peritonitis, 
indeed,  is  a  not  unfrequent  consequence. 

The  vagina  is  so  rarely  affected  that  Virchow  is  quoted  by  Courty  as 
being  the  only  observer  who  has  verified  in  this  part  the  development 
of  numerous  tubercles.  But  a  case  is  figured  further  on  (see  Fig.  157) 
from  Carswell,  in  which  the  vagina  shows  evident  marks  of  the  disease. 

In  St.  George's  Museum  (No.  xiv,  78)  is  a  good  specimen  of  scrof- 
ulous disease  of  the  uterus,  tubes,  and  both  ovaries.  The  body  of  the 
uterus  contained  a  quantity  of  lohite  soft  tubereular  matte?-,  which,  at 
the  fundus,  was  firmer  and  more  consistent,  and  with  a  definite  out- 
line penetrating,  as  it  were,  into  the  muscular  substance  of  the  uterus. 
The  Fallopian  tube  on  the  right  did  not  contain  similar  matter. 
Both  tubes  were  impervious  at  their  uterine  extremities.  The  mu- 
cous membrane  of  the  cervix  and  vagina  was  free  from  tubercular 
ulceration,  but  greatly  inflamed,  having  miliary  deposits  underneath  it. 
Both  ovaries  were  converted  into  cavities,  and  contained  remnants  of  a 
thick  semifluid  tubercular  matter.  They  were  greatly  enlarged,  and 
their  walls  much  thickened.  There  are  also  one  or  two  fibrous  tumors. 
There  existed  also  extensive  peritonitis  and  ulceration  of  the  glands,  of 
both  small  and  large  intestines,  which  in  the  rectum  had  proceeded  to 
perforation,  and  extensive  tuberculization  of  the  lungs  and  pleurisy, 


698 


TUBERCLE    OF    THE    UTERUS. 


also  scrofulous  ulceration  of  the  right  ster no-clavicular  joint.  The 
simultaneous  affection  of  ovaries,  tubes,  and  uterus,  and  general  scrof- 
ulous disease,  is  also  exemplified  in  another  specimen  in  St.  George's 
Museum  (No.  xiv,  79),  described  in  the  catalogue  as  "  Scrofulous  disease 
of  the  uterus,  Fallopian  tubes,  and  left  ovary.  The  mucous  membrane 
of  the  uterus  is  extensively  ulcerated,  and  covered  over  by  a  white 
scrofulous  deposit.  The  tubes  are  filled  with  scrofulous  deposit,  and 
are  much  distended  and  tortuous.  The  end  of  the  right  tube  is  dilated 
into  a  large  sac,  which  was  filled  with  a  white  flocculeut  creamy  fluid. 
The  left  ovary  was  converted  into  an  abscess,  containing  scrofulous  pus. 
From.  S.  H.,  aged  eighteen,  who  died  of  psoas  abscess  and  scrofulous 
disease  of  the  medulla  oblongata." 

The  specimen  from  which  Fig.  156,  Guy's  Museum,  2261''^  is  taken 
came  from  a  woman  aged  twenty-six,  Mdio  died  of  general  tuberculosis ; 


Tubercular  disease  of  uterus.    Nat.  size,  Guy's  Museum,  2261'". 
The  uterus  full  of  soft  cheesy  matter  ;  its  internal  surface  irregular  and  granular,  and  devoid  of 
mucous  membrane  ;  the  cervix  unaffected.    The  Fallopian  tubes  were  filled  with,  and  surrounded  by, 
masses  of  tubercular  deposit. 


the  thoracic  and  abdominal  viscera  being  extensively  involved  in  the 
disease.     This  specimen  is  remarkable  as  furnishing  evidence  of  the 


PATHOLOGY. 


699 


difference  in  character  of  the  mucous  membrane  of  the  body  of  the 
uterus  and  of  that  of  the  cervix.  Now  strictly  tubercular  disease  is 
limited  in  this  case  and  in  many  others  to  the  body  of  the  uterus.  In 
this  respect  tubercular  disease  stands  in  contrast  with  cancer,  which 
shows  such  a  decided  preference  for  the  cervix. 

The  ulcerative  disposition  of  uterine  phthisis  is  also  well  seen  in  the 
following  illustration  from  Carswell. 

"  This  figure  affords  a  striking  illustration  of  the  formation  of  tuber- 
culous matter  in  the  cavity  of  the  uterus  and  tubes,  as  well  as  ulcera- 
tion of  the  follicles  and  mucous  membrane  of  the  vagina,  a,  cavity  of 
uterus  laid  open,  and  nearly  filled  with  masses  of  cheesy-looking  tuber- 

FlG.  157. 


Phthisis  uteri.    (Half-size,  Carswell.) 

Tubercular  masses  in  the  mucous  membrane  of  the  body  of  the  uterus.    Ulcers  in  the  vagina. 

The  Fallopian  tubes  enlarged  by  tubercular  infiltration. 


culous  matter.  The  walls  of  the  uterus,  thicker  and  more  vascular 
than  in  the  healthy  state,  contain  two  or  three  small  masses,  6,  of  the 
same  substance.  Both  tubes,  c,  are  dilated ;  the  left  completely  filled 
with  soft  tuberculous  matter,  and  laid  open  towards  its  inferior  ex- 
tremity, that  this  substance  may  be  seen.  The  right  tube  was  filled 
with  a  turbid,  milky-looking  fluid.  The  internal  surface  of  the  vagina, 
d,  presents  a  great  number  of  ulcers,  similar  to  those  so  frequently  met 
with  in  the  trachea  of  patients  who  die  in  the  last  stage  of  phthisis. 
The  ulcers  were  apparently  formed  in  the  follicular  structure  of  the 
vagina ;  some  of  the  follicles,  enlarged,  and  presenting  a  central  open- 
ing, are  distinctly  seen  in  the  figure.     The  form  of  the  ulcers  is  round^ 


700  TUBERCLE    OF    THE    UTEPwUS. 

oval,  or  irregular,  none  of  them  larger  than  a  split  pea ;  their  edges 
sharp  and  pale ;  and  their  bottoms  either  pale  or  slightly  vascular." 

The  prognosis  is  in  all  cases  grave.  The  disease  in  the  uterus  being 
generally  secondary,  or  at  least  coincident,  with  disease  in  other  organs, 
can  rarely  admit  of  cure.  The  tendency  is  towards  extension  to  the 
tubes,  ovaries,  and  surrounding  structures.  Fatal  peritonitis  may  at 
any  time  arise.  Courty  relates  an  interesting  case  of  this  termination; 
and  other  examples  are  given  in  this  chapter. 

The  diagnosis  must  rest  greatly  upon  the  evidence  obtained  of  tuber- 
culosis in  other  parts  of  the  body,  especially  in  the  lungs.  It  is  thus 
of  a  presumptive  character.  Since  the  disease  attacks  the  body  of  the 
uterus,  leaving  the  cervix  quite  or  comparatively  free,  it  is  most  liable 
to  be  mistaken  for  malignant  disease  of  the  body,  chronic  metritis,  or 
some  forms  of  fibroid  tumor.  There  is  generally  enlargement  of  the 
body  of  the  uterus  of  a  uniform  character,  thus  differing  from  the  irreg- 
ular nodulation  of  fibroids,  and  resembling  the  enlargement  of  cancer. 
The  cases  may  also  resemble  each  other  in  the  uterus  being  fixed  by 
perimetric  deposit.  In  both  cases  there  may  be  hemorrhages  and  muco- 
purulent discharges ;  and  also  pain.  But,  as  in  other  forms  of  tuber- 
culosis, there  is  generally  amenorrhoea.  Metrorrhagia  is  exceptional. 
The  distinction  would  be  absolutely  determined  by  bringing  away  a 
small  portion  of  the  outgrowth  or  deposit  from  the  cavity  of  the  uterus. 
Under  microscopical  examination,  the  characters  of  malignant  growth 
would  come  out  in  contrast  with  those  of  tuberculous  matter.  In  either 
case,  therapeutical  considerations  would  probably  indicate  the  dilatation 
of  the  cervical  canal.  This  would  facilitate  digital  exploration,  by 
which  the  more  prominent  tumor-like  or  polypoid  character  of  malig- 
nant growths  would  be  detected. 

The  treatment  must  be  looked  upon  as  mainly  palliative.  The  gen- 
eral treatment  must  be  governed  greatly  by  the  nature  and  extent  of 
the  distant  complications.  It  is  of  the  same  kind  as  that  for  tubercu- 
losis of  the  lungs.  The  local  treatment  will  be  indicated  by  the  local 
symptoms.  If  there  be  hemorrhage  or  profuse  muco-puriform  or 
cheesy  discharge,  with  or  without  pain,  it  will  be  ])roper  to  dilate  the 
cervix  with  laminaria  or  sponge-tents  ;  and  to  swab  the  interior  of  the 
uterus  with  nitric  acid,  tincture  of  iodine,  or  acetic  acid  ;  or  iodine 
ointment  may  be  inserted  every  three  or  four  days  by  means  of  my 
ointment-carrier. 

Disinfecting  vaginal  injections  of  lead,  zinc,  or  permanganate  of  pot- 
ash will  be  useful  adjuvants. 


CANCER  OF  THE  UTEEUS.  701 


CHAPTER  L. 

CANCEK;  DEFINITION:  DEGKEES  OP  MALIGNANCY  ;  ITS  LOCAL 
OKIGIN;  HEREDITAKY  TKANSMISSION ;  ITS  EKEQUENCY; 
CAUSES;  FORMS  OF;  MEDULLARY;  EPITHELIOMA  ;  SARCOMA  ; 
SCIRRHOUS;  MYXOMA.  CANCER  AND  PREGNANCY.  THE 
COURSE  AND  TERMINATIONS  OF  CANCER;  DIAGNOSIS;  PROG- 
NOSIS. TREATMENT:  QUESTION  OF  CURABILITY;  TOTAL 
EXTIRPATION  OP  UTERUS;  AMPUTATION  OP  VAGINAL-POR- 
TION, SELECTION  OP  CASES  FOR  ;  THE  OPERATION  ;  CAUTERY, 
ACTUAL  AND  POTENTIAL.  TREATMENT  OP  CANCER  OP  BODY 
OP  THE  UTERUS.  PALLIATIVE  TREATMENT;  LOCAL  AND 
CONSTITUTIONAL. 

The  clinical  definition  of  cancer  would  be  a  disease  tending  to 
destroy  the  organ  which  it  has  attacked,  which  by  extension  invades 
the  surrounding  structures,  and  whose  tendency  is  towards  a  fatal  ter- 
mination. These  are  the  chief  characters  of  "  malignant  disease/'  This 
definition  will  embrace  several  forms  of  disease  which  differ  in  their 
histological  characters,  and  sometimes  in  their  seat  and  progress.  But 
howsoever  differing  in  other  respects,  the  common  feature  of  malig- 
nancy, that  is,  a  tendency  to  destroy  tissue,  to  spread  and  to  kill,  binds 
them  all  together  into  one  terrible  group. 

The  main  clinical  interest  attaching  to  the  differential  study  of  these 
various  forms  of  malignant  disease  lies  in  the  fact  that  they  exhibit 
different  degrees  of  malignancy,  and  that  the  seat  of  development 
materially  influences  treatment  and  the  prospect  of  giving  relief.  In- 
timately connected  with  this  point  is  the  question,  how  to  detect  the 
disease  in  its  earliest  stages  ?  The  tendency  of  modern  pathologists 
has  been  to  regard  all  cancer  as  local  in  its  origin.  A  most  hope- 
inspiring  doctrine ;  one  to  which  the  clinical  physician  should  cling  as 
that  which  most  encourages  therapeutical  research,  and  which  alone 
holds  out  a  prospect  of  ultimate  triumph  over  the  disease. 

No  one  who  is  at  the  same  time  conscientious  and  capable  of  esti- 
mating correctly  the  nature  of  cancer  will  be  rash  enough  to  hold  out 
a  confident  promise  of  cure  in  any  case.  But  surely  modern  research 
and  experience,  which  have  already  thrown  a  ray  of  light  into  what 
has  hitherto  been  regarded  as  an  impenetrable  and  perpetual  gloom, 
may  well  justify  the  hope  of  achieving  further  success. 

Willing,  more  than  willing,  to  accept  the  doctrine  that  malignant 
disease  is  local  in  its  origin,  two  circumstances  appear  to  me  to  tell 
strongly  against  it.  The  first  is  the  almost  constant  tendency  to  a 
fatal  termination  from  the  moment  when  we  have  made  an  undoubted 
diagnosis.  This  means  that  it  is  rarely  indeed  possible  to  find  the  dis- 
ease in  its  presumed  strictly  local  initiative  condition.    From  its  earliest 


702  CANCER  OF  THE  UTERUS. 

discovery  it  has  already  effected  a  strong  hold  upon  the  constitution. 
The  other  circumstance  is  the  hereditary  force  of  the  disease.  There 
is  a  general  consent  among  surgeons  upon  this  point.  It  constitutes 
one  of  its  greatest  terrors.  And  yet  it  is,  I  venture  to  think,  somewhat 
exaggerated.  Lebert,  for  one,  disputes  the  hereditary  force.  Looking 
back  to  ray  own  experience  I  can  recall  many  instances  of  isolated  cases 
of  cancer  in  a  family  to  set  against  other  cases  of  recurrence.  Espe- 
cially in  one  very  large  family,  whose  history  I  have  known  for  three 
generations,  there  has  been  one  solitary-  instance  of  cancer. 

But  there  is  another  fact  which  bears  uj^jon  the  question  of  hereditary 
and  of  constitutional  diathesis.  Some  diatheses  seem  interchangeable 
or  coexistent ;  or  we  might,  to  invoke  another  hypothesis,  say  that  all 
morbid  diatheses  are  one  in  their  ultimate  analysis,  and  that  the  devel- 
opment of  phthisis  in  one  person,  of  brain  disease  in  another,  and  of 
cancer  in  a  third,  is  determined  by  various  secondary  conditions.  This 
hypothesis  is  not  contradicted  by  the  apparent  incompatibility  of  two 
diatheses  in  marked  development  in  the  same  individual.  This  incom- 
patibility is  only  apparent.  A  person  struck  with  cancer,  for  example, 
will  be  destroyed  by  this  disease  before  phthisis  can  be  developed,  and 
vice  versa.  And  the  coexistence  of  the  affections  is  not  rare.  That 
consummate  pathologist,  Mr.  Hutchinson,  called  my  attention  to  this 
fact  in  reference  to  a  case  in  point  under  our  care.  He  observed  that 
the  diathesis  which  produced  one  form  of  local  disease,  say  in  the 
ovary,  would  often  be  manifested  by  the  development  of  other  forms, 
as  of  fibroids  in  the  uterus.  Of  the  truth  of  this  remark  we  may  see 
abundant  proofs.  And  if  we  extend  our  observation  beyond  the  indi- 
vidual, looking  to  the  family,  we  cannot  fail  to  see  frequent  examples 
of  various  manifestations  of  the  original  taint,  showing  itself  as  phthisis 
in  one  member,  cancer  in  another,  and  nervous  disease  in  a  third. 

Next  to  cancer  of  the  breast,  says  Samuel  Cooper,  cancer  of  the 
womb  is  the  form  in  which  the  disease  most  frequently  presents  itself. 
Sometimes  the  disease  takes  place  in  the  womb  and  breast  together ; 
and  Cruveilhier  records  an  instance  in  which  cancer  uteri  was  accom- 
panied by  a  medullary  tumor  in  the  substance  of  the  left  hemisphere  of 
the  brain,  so  that,  in  the  latter  stages  of  the  case,  the  patient  was  attacked 
with  convulsions  and  hemiplegia.  According  to  this  distinguished 
pathologist,  however,  notwithstanding  the  tendency  of  cancerous  dis- 
eases in  general  to  affect  the  whole  economy,  by  extending  from  the 
point  first  attacked,  as  from  a  centre,  cancer  of  the  womb  is  but  rarely 
accompanied  by  this  general  implication  of  the  system,  and  especially 
of  the  breast. 

It  appears  also,  from  Cruveilhier's  researches,  that  the  vagina  is  as 
frequently  the  seat  of  cancer,  as  the  neck  of  the  womb.  "Its  anterior 
paries  is  much  more  frequently  attacked  than  its  posterior ;  and  hence 
it  is  rare  to  find  instances  in  which  the  lower  portion  of  the  bladder 
does  not  particii)ate  in  the  disease."  (Anat.  Pathol,  liv.  xxiii,  pi.  6.) 
But  in  some  cases,  no  doubt,  the  disease  begins  in  the  bladder,  extend- 
ing to  the  uterus  as  in  a  specimen  (Ea.  7)  in  the  London  Hospital. 

Cancer  of  the  uterus  may  originate  at  any  period  after  puberty ;  but 
the  time  of  life  between  the  ages  of  forty  and  fifty  is  that  in  which  its 


PATHOLOGY.  703 

commencement  is  most  common.  A  specimen  of  cancer  affecting  the 
uterus  and  vagina  in  an  infant  nine  months  old  was  exhibited  to  the 
Obstetrical  Society  by  Mr.  Heckford,  surgeon  to  the  East  London 
Children's  Hospital  (Obstetrical  Transactions,  1868).  Cruveilhier  ob- 
serves, that  from  the  age  of  thirty-five  to  tliat  of  fifty  is  the  principal 
season  for  this  cruel  disease,  though  he  has  known  one  woman  of  the 
town  die  of  it,  whose  age  was  only  twenty -six ;  and  has  seen  it  in 
women  as  old  as  sixty,  seventy,  eighty,  and  even  eighty-three.  In  St. 
George's  Museum  is  a  specimen  showing  the  disease  at  the  age  of  ten 
(No.  xiv,  82).  The  walls  of  the  uterus  are  greatly  distended,  and  its 
cavity  filled  by  a  large  encephaloid  growth,  which,  originating  in  the 
muscular  structure,  on  the  left  side,  appears  to  have  made  its  way  into 
the  cavity  as  well  as  outwards.  A  red  discharge  had  taken  place  from 
the  uterus,  which  led  her  parents  to  believe  she  was  menstruating. 
Mesentery,  liver,  and  pancreas  were  extensively  diseased  with  cancer. 

The  cases  cited  of  the  disease  occurring  in  children  are  sufficient  to 
prove  that  it  may  occur  in  single  women,  and  in  those  who  have  never 
been  pregnant.  But  although  I  have  met  with  it  in  single  and  sterile 
women  of  all  ages,  I  entertain  a  strong  opinion  that  it  is  far  more 
common  in  those  who  have  borne  children.  Ovarian  disease  more 
peculiarly  affects  the  single  and  the  sterile.  Numerical  statements  of 
Scanzoni  and  Sibley  go  to  establish  this  view.  The  pathological  in- 
ference would  be  that  functional  activity  is  a  predisposing  cause,  or 
that  the  changes  started  in  the  structure  and  nutrition  of  the  uterus  by 
labor  favor  the  selection  of  this  organ  for  the  manifestation  of  a  general 
diathesis.  This  seems,  as  we  have  seen,  to  be  clearly  so  in  the  case  of 
tuberculosis. 

The  question  is  sometimes  anxiously  asked  whether  cancer  of  the 
uterus  is  not  contagious  f  If  it  be  propagated  by  cell-growths,  which 
may  be  regarded  as  germs,  it  seems  a  not  unreasonable  conjecture  that 
the  malignant  cells  may  be  transplanted  or  grafted  upon  the  tissues  of 
another  person,  and  grow  in  this  new  nidus  just  as  they  do  by  exten- 
sion in  the  original  subject.  I  do  not  know,  however,  of  any  une- 
quivocal facts  to  favor  this  idea.  I  have  known,  of  course,  as  every 
physician  of  experience  must  know,  of  many  cases  of  husbands  living 
with  their  wives  long  after  the  disease  had  been  recognized ;  but  I 
have  not  known  of  a  single  instance  of  the  disease  being  propagated. 
Possibly  grafting  on  a  raw  surface  is  necessary ;  and  probably,  the 
malignant  cells  will  only  retain  their  vitality  in  tissues  of  congenial 
morbidity. 

Cruveilhier  finds,  that  what  he  terms  the  areolar  'pultaceous  cancer, 
is  the  most  frequent  of  all  the  forms  of  cancer  to  which  the  uterus  is 
liable.  In  this  the  uterus  is  transformed  into  a  spongy  texture,  from 
which  a  cancerous  substance,  of  greater  or  less  consistence,  may  be  com- 
pressed in  the  shape  of  small  worms  ;  so  that,  when  this  texture  has 
been  emptied  by  suitable  preparation,  a  hollow  cellular  structure  re- 
mains. Cruveilhier  conceives  that  he  has  made  out  the  fact,  that  cancer 
of  the  uterus  begins  in  the  venous  system.  However  this  may  be,  he 
notices  another  tact,  which  is  of  greater  importance  to  the  practitioner, 
viz.,  that  the  lymphatic  glands  in  the  -pelvis  are  almost  constantly  affected 


704  CANCER    OF    THE    UTEEIJS. 

in  cancer  of  the  womb.  He  specifies  in  particular  two  glands,  situated, 
one  to  the  right  and  the  other  to  the  left,  at  the  sides  of  the  pelvis,  on 
a  level  with  the  highest  part  of  the  ischiatic  foramen :  these,  he  says, 
are  often  the  only  lymphatic  glands  implicated.  The  lumbar  glands 
he  finds  less  frequently  diseased  than  the  pelvic ;  and  he  states,  that 
they  may  be  enlarged  and  red  without  presenting  any  vestige  of  can- 
cerous structure.  The  inguinal  glands  are  only  involved  when  the 
disease  attacks  the  external  pudenda,  and  the  orifice  of  the  vagina.  In 
only  one  dissection  he  found  the  cancerous  substance  in  the  thoracic 
duct,  though  he  examined  it  at  every  opportunity ;  and,  in  another 
instance,  he  traced  the  same  substance  in  many  of  the  lymphatics, 
which  proceeded  from  the  diseased  parts.  [Op.  cit,  liv.  xxvii.)  I 
have,  however,  traced  it  along  the  iliac  veins  into  the  vena  cava.  In 
one  case,  dissected  by  Cruveilhier,  one  ureter  was  enormously  dilated, 
and  the  corresponding  kidney  wasted.  "The  relations  of  the  ureters 
with  the  lateral  and  superior  part  of  the  vagina,  and  with  the  lower 
part  of  the  bladder,  which  is  often  implicated  in  cancer  of  the  uterus, 
account  for  the  impediment  to  the  flow  of  the  urine  through  the  ureters, 
the  lower  portions  of  which  are  often  surrounded  by  cancerous  masses, 
which  compress  them.  This  compression  may  take  place  in  so  great 
a  degree,  that  the  lower  part  of  the  ureter  is  completely  obliterated ; 
and,  what  is  remarkable,  such  compression  does  not  produce  the  fatal 
consequences,  which  theoretically  might  be  expected.  The  urine  dilates 
the  ureter  (see  Cruveilhier,  liv.  xxvii,  pi.  2,  Fig.  2),  which,  at  the  same 
time  that  it  becomes  dilated,  is  lengthened  and  rendered  tortuous  or 
spiral,  like  a  varicose  vein.  The  pelvis  and  calices  in  their  turn  are 
also  expanded,  so  as  to  acquire  a  considerable  capacity.  The  kidney, 
compressed  by  the  urine,  accumulated  in  the  dilated  calices,  gradually 
wastes  away,  and  is  converted  into  a  mere  shell  or  husk,  of  a  pale  yellow, 
having  some  resemblance  in  color  to  the  changed  state  of  the  kidney, 
known  of  late  by  the  name  of  Bright's  disease ;  and  such  atrophy  may 
proceed  so  far  that  no  urine  can  be  secreted,  or  so  little,  that  any  re- 
dundance may  be  easily  prevented  by  absorption."  The  possibility  of 
life  continuing  long,  with  an  obstruction  of  both  ureters,  would  be, 
however,  a  very  different  case  from  that  described  by  Cruveilhier. 

Gangrene,  consequent  to  cancer  of  the  womb,  is  found  by  Cruveilhier 
to  be  very  common,  sometimes  destroying  the  cancerous  structure, 
layer  by  layer,  and  in  other  instances  attacking  the  whole  mass  of  it. 
In  both  cases,  the  discharge  becomes  horribly  fetid,  and  when  the 
finger  is  withdrawn  from  the  vagina,  it  brings  away  a  sloughy  putrid 
detritus,  which  Cruveilhier  says  can  be  compared  to  nothing  more 
like  it  than  the  substance  into  which  hospital  gangrene  transforms  the 
textures  invaded  by  it.  The  sloughing  may  advance  slowly  or  rap- 
idly ;  a  difference  which  has  vast  influence  on  the  intensity  and  acute- 
ness  of  the  symptoms.  When  gangrene  attacks  the  whole  of  the  can- 
cerous mass,  and  nearly  annihilates  it,  the  case  might  be  mistaken  for 
one  of  primary  mortification ;  and,  in  many  examples,  the  cancerous 
state  of  the  pelvic  and  lumbar  absorbent  glands  is  the  only  criterion 
of  the  gangrene  having  been  preceded  by  a  cancerous  affection  of  the 
uterus.     (Cruveilhier,  Anat.  Pathol.,  liv.  xxiv.) 


FORMS.  705 

All  the  known  forms  of  cancer  may  affect  the  uterus. 

1st,  Fungoid  or  medullary  carcinoma  is  by  far  the  most  common  ; 
2dly,  in  frequency,  come  the  epithelial  kinds;  3dly,  sarcoma;  and 
4thly,  the  scirrhous  or  hard  cancer.  This  last,  West  and  Rokitansky 
say,  is  extremely  rare. 

Each  of  these  forms  has  its  own  characters  of  evolution  and  of 
structure,  and  these  entail  differences  in  clinical  features.  True  cancer, 
says  H.  Arnott,  includes  those  cases  in  which  a  structure  more  or 
less  resembling  that  of  a  scirrhous  breast  is  met  Avith,  namely,  an  alve- 
olar fibrous  stroma,  in  the  interstices  of  Avhich  float,  in  a  clear  fluid 
and  with  no  visible  intercellular  material,  cells  of  varying  shape,  but 
all  approximating  somewhat  to  the  squamous  epithelial  type,  and 
containing  usually  only  one  large  oval  nucleus  with  bright  nucleolus. 
In  many  cases  the  fibrous  stroma,  instead  of  forming  a  dense  network, 
is  visible  only  as  a  thin  streak  here  and  there,  and  in  these  cases  the 
varied  shapes  of  the  cells,  and  the  absence  of  the  intercellular  sub- 
stance, stamp  the  cancerous  nature  of  the  growth.  The  cells  occasion- 
ally contain  multiple  nuclei.  In  some  places  Arnott  thought  he  could 
trace  a  development  of  the  cancer-structure  from  surrounding  "  ade- 
noid," or  lymphatic  glandlike  material,  the  cells  of  the  new  growth 
taking  the  place  of  the  small  nuclei  in  the  fibrous  stroma  of  this  struc- 
ture ;  but  more  generally  the  cancer  seemed  to  be  splashed  in,  so  to 
say,  amongst  healthy  uterine  tissue.  But  separate  nodules  of  the  new 
formation  are  rarely  met  with  imbedded  in  parts  of  the  uterus  at  a 
distance  from  the  ulcerated  portion. 

1.  The  Medullary  Cancer,  or  Encephaloid. — This  has  its  special  seat 
in  the  connective  tissue  or  stroma.  It  is  found  as  a  thick,  bony,  hard, 
nodular  mass,  of  white,  gray,  or  red  color,  consisting  of  a  fibrous 
framework,  with  a  brainlike  pulp  in  the  interstices.  As  a  rule,  cancer 
is  characterized  by  an  infiltration  of  cells  of  a  monstrous  type,  and 
great  activity  of  multiplication,  into  the  natural  areolar  tissue.  Wher- 
ever areolar  tissue  is  found,  there  cancer  is  prone  to  form.  In  uterine 
encephaloid,  these  cells  commence  in  the  cellular  tissue  between  the 
mucous  membrane  and  the  proper  tissue  of  the  uterus.  Lebert  thinks 
cancer  may  begin  in  the  follicles  of  the  neck  of  the  uterus.  The  dis- 
ease gradually  encroaches  upon  the  deeper  strata ;  but  commonly  there 
remains  after  death  a  thin  layer  of  muscular  substance  beneath  the 
peritoneal  investment  of  the  uterus.  The  extension  is  not  so  much  in- 
wards into  the  uterine  tissue,  as  centrifugal.  At  first  this,  like  the 
other  forms  of  cancer  of  the  uterus,  appears  to  be  strictly  local,  con- 
fined to  the  cervix.  But  after  a  time,  difficult  to  determine,  the  dis- 
ease invades  the  areolar  tissue  of  the  fundus  of  the  vagina,  the  base 
of  the  bladder,  the  rectum,  the  broad  ligaments,  uniting  all  these  parts 
into  one  mass.  As  the  cell-growth  proceeds,  the  normal  elements  of 
the  parts  invaded  disappear.  The  diseased  mass  increases  in  size, 
reaching  often  a  considerable  bulk,  so  that  the  finger,  scarcely  intro- 
duced through  the  vulva,  will  in  cases  somewhat  advanced  at  once 
strike  upon  it.  The  deformed  os  uteri  is  brought  low  down,  as  in  pro- 
lapsus. It  is  often  hardly  recognizable  from  the  nodular,  irregular 
projections  and  fissures  which  surround  it.     It  is  sometimes  occluded 

45 


706  CANCER    OF    THE     UTERUS. 

by  these,  but  more  often  held  unnaturally  patulous.  In  this  stage, 
the  cervix  uteri  being  involved  in  a  growth  extending  to  all  the  sur- 
rounding structures,  is  set  fast;  it  has  lost  all  mobility;  or,  if  auy  re- 
main, it  moves  only  with  the  whole  diseased  mass. 

The  next  feature  of  importance  in  the  history  is  the  marked  ten- 
dency to  softening  and  suppuration.  Softening  is  soon  followed  by 
death  of  the  mucous  membrane  of  the  os  uteri;  "an  ulcer  (West) 
forms,  with  raised,  irregular,  hardened  edges,  and  a  dirty  putrilage 
takes  the  place  of  the  smooth  but  enlarged  lips  of  the  os.  The  disease 
may  go  still  further ;  the  lips  of  the  womb  and  its  cervix  are  altogether 
destroyed,  and  a  soft,  dirty-Avhite,  flocculent  substance  covers  the  uneven 
granular  and  hardened  surface.  The  ulceration  may  begin  in  the  sub- 
stance from  softening,  or  on  the  surface  without  previous  softening  in 
the  deeper  parts." 

The  stage  before  ulceration  varies  much  in  duration.  In  many  cases 
it  is  certain  that  the  extension  of  the  disease  has  greatly  advanced  be- 
fore the  patient  seeks  advice.  Probably  a  year  or  more  may  elapse 
before  ulceration  occurs.  The  duration  of  the  stage  of  ulceration  is 
also  variable.  Sometimes  it  runs  through  this  stage  rapidly;  at  others, 
the  ulceration,  without  healing  or  spreading  much,  is  kept  up  for 
months.  The  patient  indeed  grows  worse,  losing  flesh  and  strength, 
assuming  the  characteristic  worn,  straw-colored,  cachectic  look.  The 
discharges  continue,  composed  of  pus  from  the  ulcerated  surface,  fetid 
from  the  admixture  of  dead  and  decaying  materials,  tinged  with  blood 
from  the  giving  way  of  some  of  the  vessels  distributed  to  the  granula- 
tions, while  every  now  and  then  abundant  hemorrhages  break  forth. 
If  we  examine,  we  find  sprouting  granulations  or  a  positive  fungous 
outgrowth  from  the  surface,  and  then  after  a  time  the  fungus  disappears, 
the  surface  feels  less  uneven,  the  edges  less  uuhealthy,  and  we  can  al- 
most persuade  ourselves  that  here  and  there  a  process  of  cicatrization 
has  begun.  New  formation  and  death  of  the  newly-formed  tissues  go 
on  in  rapid  succession — a  series  of  abortive  attempts  at  cure,  such  as 
prevent  the  rapid  extension  of  the  ulcer,  and  keep  alive  the  delusive 
hope  of  recovery.  And,  indeed,  under  the  spontaneous  or  assisted 
powers  of  nature,  it  is  not  uncommon  for  the  disease  to  exhibit  stages 
of  apparent  arrest,  during  which  the  discharges  are  lessened,  the  local 
suffering  is  abated,  and  the  general  health  improves.  But  sooner  or 
later,  relapse  is  but  too  sure,  and  the  patient  at  length  sinks  under  the 
exhaustion  consequent  upon  repeated  discharges — watery,  purulent,  and 
hemorrhagic — pain,  obstruction  to  the  rectum  and  bladder  in  the  per- 
formance of  their  functions,  and  impairment  of  nutrition. 

Fig.  158,  p.  707,  exhibits  the  action  of  medullary  cancer  upon  the 
uterus.  The  cervix  and  lower  part  of  the  body  are  principally  af- 
fected, but  the  body  of  the  uterus  is  sensibly  enlarged. 

Fig.  159,  p.  708,  shows  that  the  encephaloid  form  may  invade  the 
body  as  well  as  the  cervix. 

As  the  disease  advances  upwards  into  the  cervix,  eating  away  the 
tissues,  a  large  gaping  cavity  with  irregular  edges  is  formed,  sometimes 
extending  by  fistulous  passages  into  the  bladder  and  rectum.     So  strict 


PATHOLOGY. 


707 


is  the  apparent  limitation  of  the  disease  to  the  cervix  in  some  cases, 
that  tliis  part  is  completely  eaten  away,  leaving  the  body  almost 
intact.  (See  Figs.  160,  161,  p.  709.)  But,  although  primary  cancer 
of  the  body  of  the  uterus  is  rare,  the  disease  will  generally  spread 
to  it  from  the  cervix  if  the  patient's  life  be  sufficiently  protracted.  In 
advanced  cases  the  body  of  the  uterus  is  almost  always  enlarged,  and 

Fig.  158. 


Cancer  of  uterus.     (Ad  nat.,  St.  Bartholomew's  Museum,  .32'^) 
The  lower  two-thirds  of  the  walls  are  enlarged  by  the  infiltration  of  a  soft  medullary  substance. 
The  natural  texture  of  the  organ  can  hardly  be  discerned.    The  disease  forms  a  large  spheroidal 
mass,  of  which  the  lower  surface,  projecting  in  the  vagina,  is  ulcerated  and  flocculent. 


this  from  two  causes.  The  maintenance  of  an  active  parasitic  growth, 
like  cancer,  attracts  blood  to  the  organ ;  it  grows  under  this  morbid 
stimulus  as  it  will  under  that  of  developing  a  fibroid  tumor,  or  as 
under  the  normal  stimulus  of  gestation.  In  addition  there  is  an  ex- 
tension of  the  cancerous  growth.  The  mucous  membrane  of  the  body 
is  more  generally  affected.  Sometimes  nothing  more  is  apparent  than 
a  general  and  intense  redness  of  the  interior  of  the  womb ;  but  much 
more  frequently  the  lining  membrane  is  covered  by  a  dark  offensive 
secretion,  and  is  beset  here  and  there  by  small  white  deposits  of  cancer. 
The  irritation  caused  by  the  morbid  condition  of  the  body  of  the 
uterus  will  often  set  up  a  slow  or  chronic  inflammation  in  the  broad 
ligaments  and  pelvic  peritoneum.     The  fibrinous  effusions  resulting 


708 


CAJS^CER    OF    THE     UTERUS, 


bind  the  uterus  to  the  bladder  and  rectum,  adding  to  the  mass  formed 
by  the  cancerous  deposit,  and  still  further  determine  that  firm  fixing 
of  the  uterus  in  the  pelvic  cavity  which  is  observable  in  almost  every 
instance  of  carcinoma  of  the  medullary  kind,  except  in  the  very  earliest 
stage.     Cancerous  deposits  take  place  under  the  pelvic  peritoneum ; 


Fig.  159. 


Uterus  greatly  enlarged  from  infiltration  with  encephaloid  matter.    (Half-size,  St.  Thomas's 

Museum,  GG4.3.) 
The  uterus  measures  nearly  five  inches  across;  its  walls  are  one  and  a  quarter  inche.s  in  thickness, 
except  at  the  upper  part,  where  they  are  somewhat  less.  This  is  due  to  infiltration  with  cancerous 
deposit,  which  exists  in  greater  abundance  in  the  inner  two-thirds  of  the  muscular  parietes;  this 
part  presents  a  spongy  appearance  where  the  deposit  has  been  partly  washed  out.  The  os  and  cervix 
uteri  participate  in  the  enlargement.  Several  spongy-looking  cauliflower  fungoid  growths  project 
from  the  parietes  into  the  cavity  of  the  uterus  ;  their  reticulate  and  spongy  appearance  is  also  due  to 
the  encephaloid  material  having  been  partly  washed  out. 


extending,  the  peritoneum  is  involved,  and  at  length  is  indistinguish- 
able in  the  mid.st  of  the  large  mass  of  cancerous  disease  which  conceals 
the  uterus  and  its  appendages  from  view.  Towards  the  end  hemor- 
rhages often  stop,  but  the  watery  purulent  discharges  increase  in  quan- 
tity; whilst  the  ansemic  cancerous  cachexia,  pain  and  sleeplessness,  and 
spasms,  with  disturbances  of  the  alimentary  canal,  increase. 

Figs.  160,  161,  show  the  ravages  made  by  the  destructive  necrotic 
ulcerative  process  when  the  disease  is  chiefly  limited  to  the  cervix.  In 
Fig.  160  the  body  of  the  uterus  is  evidently  affected.  In  Fig.  161  the 
body  remains  almost  intact,  although  the  lo\ver  part  of  the  uterus  is 
literally  eaten  away. 

It  is  in  this  way  that  the  vagina,  being  destroyed  at  the  fundus  and 
upper  part  of  its  anterior  and  posterior  walls,  the  septa  between  uterus 
and  vagina  and  the  bladder  and  rectum  being  destroyed,  the  three 
canals  are  thrown  into  one  common  cloaca,  which  receives  all  the  ex- 
creta. 

2.  Epithelioma,  according  to  Mr.  Arnott,  is  characterized  by  an  ac- 
cumulation of  ordinary  or  hypertrophied  epithelial  scales  in  an  unnat- 
ural  position,  sometimes   accompanied    by   nests,  or   "globes  epider- 


EPITHELIAL    FORM. 


709 


miques,"  although  not  necessarily  so  distinguished,  and  with  usually 
a  very  disorderly  clustering  of  the  scales,  which  are  otherwise  disposed 


Fig.  160. 


Uterus,  of  which  the  luwei  t«'o-thi>db  hiive  been  destroyed  by  ulceration,  of  cancerous  nature. 
The  adjacent  part  of  the  \agina  is  superficially  ulcerated.  (Two-third  size,  St.  Bartholomew's  Mu- 
seum.) 

with  cohering  edges.     In  some  cases  a  section  carried  throuo;h  the  mu- 
cous  membrane  of  the  cervix  close  to  the  ulceration  showed  hyperplasia 

Fir.  151. 


Cancer  eating  away  the  lower  half  of  the  uterus  and  perforating  into  the  bladder.     (Half-size, 
St.  Thomas's  Museum,  G  G  55.) 


710  CANCER  OF  THE  UTERUS. 

of  the  epithelial  elements  upon  and  between  the  papillae,  with  infiltra- 
tion of  the  same  elements  amongst  the  deeper  structures  ;  other  sections 
from  a  more  diseased  portion  of  the  same  uterus,  exhibiting  only  the 
confused  heaps  of  epithelial  cells,  with  much  broken-down,  oily  or 
granular  debris. 

The  caulifloiver  excrescence  of  Dr.  John  and  Sir  Charles  Clarke  is  the 
best  known  form  of  the  epithelial  cancer  of  the  uterus.  It  appears  from 
Gooch's  criticism  to  be  the  same  disease  as  was  described  by  Levret 
and  Herbiniaux,  under  the  name  of  "turaeur  vivace."  It  also  affects 
by  preference  the  cervix.  Epitheliomata  take  their  habitual  origin  in 
the  epithelial  layer  of  the  upper  part  of  the  vagina  and  os  uteri.  Here 
the  epithelial  buds  become  developed,  and  form  a  tumor,  which  projects 
into  the  vagina.  Opinions  differ  as  to  its  malignancy.  Rokitansky 
believes  it  to  be  cancerous,  calling  it  the  villous  cancer.  He  describes 
it  as  a  conferv^a-like  growth,  consisting  of  corpuscles  the  size  of  linseed 
grains,  pale  red,  transparent,  tolerably  firm,  hanging  from  the  os  uteri 
into  the  vagina,  bleeding  profusely  on  the  slightest  touch,  and  devel- 
oped out  of  an  encephaloid.  It  often  fills  the  vagina,  and  causes  pro- 
fuse watery  secretion.  During  life  it  becomes  turgescent,  like  the 
uterine  surface  of  the  placenta;  but  dead,  it  shrivels  up,  and  then  only 
resembles  a  flocculent  mass. 

Virchow,  on  the  other  hand,  says  it  is  not  cancerous,  ranking  it 
under  the  papillary  tumors,  of  which  there  are  three  forms, — the  simple, 
the  cancroid,  and  the  cancerous.  The  cauliflower  excrescence,  accord- 
ing to  him,  begins  as  a  simple  papillary  tumor,  and  runs  into  cancroid, 
but  not  into  cancerous  papillary  tumor.  It  is  formed  only  of  papillary 
or  villous  growths,  which  consist  of  thick  layers  of  peripheral  flat  and 
cylindrical  epithelial  cells,  and  a  fine  inner  cylinder  of  extremely  small 
cellular  tissue  with  large  vessels,  running  in  loops.  This  tumor  is  also 
called  papillary  hypertrophy  of  the  cervix  uteri.  Mayer  regarded  it  as 
an  originally  local  affection.  Hannover  separates  it  from  cancer,  under 
the  name  of  epithelioma.  Lebert  and  Schutz  call  it  epithelial  cancroid. 
Virchow  points  out  that  the  forms  which  yield  dry,  juiceless  masses 
are  relatively  benignant;  -whilst  those  which  produce  succulent  tissues 
have  always  more  or  less  a  malignant  character. 

Cancroid  remains  for  a  long  time  local. 

Fig.  162  shows  epithelioma  in  an  early  stage.  It  consisted  of  epithe- 
lial cells  and  "  epidermic  globes ;"  some  of  the  cells  had  multiple  nuclei. 
The  subject  was  thirty-eight  years  old,  pluripara.  After  suffering  for 
several  months  from  white  and  red  discharges,  pains  in  the  hypogas- 
trium  and  loins,  she  was  admitted  to  the  Hotel  Dieu  with  severe  flood- 
ing; a  second  flooding  carried  her  off'.  The  pelvic  and  lumbar  glands 
were  unaffected. 

Fig.  163  seems  to  be  an  example  of  epithelioma  affecting  the  body  of 
the  uterus. 

The  divergence  of  opinions  as  to  the  cancerous  nature  of  this  growth 
is  difficult  to  reconcile.  But  if  it  be  admitted — and  clinical  observation 
dictates  the  admission  —  that  the  cauliflower  excrescence  frequently 
springs  from  a  base  of  medullary  cancer,  or  at  some  stage  is  associated 
with  cancer,  there  is  strong  ground  for  taking  the  more  unfavorable 


EPITHELIAL    OR    CANCROID.  711 

view.     Certainly,  in  some  cases  the  cauliflower  form  becomes  lost  in 
the  ordinary  characters  of  medullary  cancer ;  appearing  to  be  simply  a 


Paveinent-epithelioma  of  uterus.    (Half-size,  early  stage.    After  Lancereaux.) 

The  uterus  laid  open,    e,  mamillary  vegetation  filling  the  vaginal  cul-de-sac  and  almost  covering  the 

OS  uteri ;  u,  softening  and  ulceration  of  the  vaginal  mucous  membrane. 

phase  in  the  development,  of  the  latter.  Moreover,  with  cauliflower 
excrescence  of  the  uterus,  malignant  disease  of  undoubted  form  is  occa- 
sionally found  in  other  parts  of  the  body.  At  the  same  time  it  is  emi- 
nently important  in  a  therapeutical  aspect,  to  bear  in  mind  the  appar- 
ently lesser  degree  of  malignancy  of  the  cauliflower  excrescence,  and  its 
greater  concentration  in,  or  limitation  to,  the  vaginal-portion  of  the 
cervix,  up  to  a  certain  period  of  its  growth,  than  is  at  all  common  with 
regard  to  the  medullary  cancer.  Ablation  of  the  growth  by  amputation 
of  the  vaginal-portion  is  fairly  successful,  if  performed  during  the  stage 
of  localization. 

It  is  not  easy  to  get  an  opportunity  of  examining  the  disease  in  its 
initiative  stages.  The  symptoms  produced  are  not  such  as  to  lead  the 
patient  to  seek  advice.  Dr.  West  says,  when  he  has  first  seen  it,  the 
cervix  has  been  already  somewhat  increased  in  size,  the  os  uteri  not 
open,  but  its  lips  flattened  and  expanded,  so  that  their  edge,  which  felt 
a  little  ragged,  projected  a  line  or  two  beyond  the  circumference  of  the 
cervix,  while  their  surface  was  rough  and  granular.  This  irregularity 
was  seen  to  be  produced  by  the  aggregation  of  numerous  small,  some- 
what flattened,  papillae  of  a  reddish  color,  semi-transparent,  and  often 
bleeding  very  easily.  Generally  these  small  papillae  increase  in  size, 
and  form  a  distinct  outgrowth  from  the  whole  circumference  of  the  os 
uteri  of  the  size  of  an  Q^g,  an  apple,  or  even  larger.  These  growths 
are  split  up  by  deep  fissures  into  lobules  of  various  size,  all  of  which 
seem  to  be  connected  together  at  their  base.  The  dimensions  of  these 
growths  are  not  in  general  the  same  throughout,  but  they  spring  from 
the  surface  of  the  os  uteri  by  a  short,  thick  pedicle,  which  is  the  elon- 


712 


CANCER    OF    THE    UTERUS.  ' 


gated  and  hypertrophied  cervix,  and  then  expand  below  into  the  pecu- 
liar cauliflower  shape.  At  the  base  the  substance  is  much  firmer. 
Though  the  vagina  does  not  by  any  means  escape  from  participation 


Malignant  disease  of  the  uterus,  whicli  has  become  brolteu  down,  the  result  of  ulceration  (sometimos 

called  cauliflower  excrescence).    (Ad  nat.,  St.  George's  Museum,  xiv,  84.) 

The  patient  labored  under  a  discharge  from  the  vagina.    A  fungus  excrescence  is  seen  growing  from 

the  fundus.    She  had  scirrhus  of  the  breast,  and  fungus  hrematodes  of  the  liver. 


in  the  disease,  and  a  granular  or  papillary  structure  may  be  felt  some- 
times extending  over  its  roof,  and  for  some  distance  along  one  or  other 
wall,  yet  this  is  by  no  means  constant.  The  tendency  to  involve  adja- 
cent parts  is  far  less  than  in  ordinary  cancer.  Usually  the  outgrowth, 
in  the  course  of  time,  disappears  in  part,  under  the  processes  of  alter- 
nate partial  death  and  reproduction  which  characterize  the  medullary 


SAECOMA.  713 

cancer.  The  irregular,  sharp-cut  edge  of  the  os,  whence  it  grew,  is  at 
first  felt  granular  and  mucous  within,  but  afterwards  grows  thicker  and 
nodulated,  assuming  by  degrees  all  the  characters  of  a  part  which  has 
from  the  first  been  the  seat  of  medullary  cancer. 


Cauliflower  growth  of  the  cervix  uteri  (sarcoma).    (By  H.  Arnott.) 
From  a  specimen  furnished  by  the  author,  removed  by  galvano-caustic  operation. 

3.  Spindle-cell  sarcoma  is  a  structure  made  up  of  densely-packed 
cells  having  a  spindle  shape,  being  usually  arrayed  in  a  tolerably  reg- 
ular manner,  and  containing  generally  single,  rarely  two,  compara- 
tively large  oval  nuclei.  In  neither  of  the  cases  of  uterine  sarcoma 
was  anything  like  encapsulation  observed,  either  in  the  uterus  or  in 
the  nodules  in  the  lungs  or  glands.  The  sarcoma  in<this  respect  fol- 
lowed Mdiat  Mr.  Arnott  believes  to  be  the  general  rule,  although  sar- 
comatous tumors  are  thought  by  many  to  be  usually  invested  by  a  cap- 
sule of  some  kind,  instead  of  freely  infiltrating  surrounding  tissues. 

The  following  example  (Fig.  165)  of  spindle-cell  sarcoma  is  taken 
by  kind  permission  from  Mr.  H.  Arnott's  work.^ 

Gusserow  (Archiv  fur  Gynilkol,  1870)  says  sarcoma  is  often  con- 
founded with  carcinoma  and  cancroid.  He  says  C.  Mayer,  Virchow, 
L.  Mayer,  Weit,  and  West  give  cases  of  hard  sarcoma  under  the  name 
of  "  recurrent  fibroids."  The  recurrence  is  tardy  compared  with  that 
of  cancer,  but  some  cases  have  been  rapidly  fatal.  There  can  be  no 
doubt,  he  says,  that  true  fibroma  may  pass  into  sarcoma  by  the  exag- 
geration of  its  cellular  elements. 

Further  observations  are  necessary  to  determine  how  far  Gusserow's 
statement  that  sarcoma  is  the  special  disease  of  the  body  of  the  uterus 
is  correct.  Consulting  my  colleague,  Mr.  Arnott,  upon  this  point,  he 
tells  me  that  in  the  few  cases  he  has  studied,  the  sarcoma  has  not  been 
limited  to  the  fundus.     In  one  case  of  this  kind  in  which  os  and  cervix 

1  -'Cancer:  its  Varieties,  their  History,  and  Diagnosis,"  by  Henry  Arnott, 
F.Pv.C.S.     1872. 


714 


CANCER    OF    THE    UTERUS. 


alone  remained  unaffected,  the  disease  was  distinctly  carcinomatous. 
On  the  other  hand,  the  only  other  case  he  has  seen  (shown  by  the  late 
A.  Bruce,  and  reported  upon  by  W.  Fox,  Hulke,  and  Cay  ley,  Path. 
Trans.,  vol.  xviii),  which,  although  called  cancer  was  clearly  sarcoma, 
did  show  a  nodule  in  the  fundus  of  the  uterus,  the  os  remaining  free. 
But  this  was  a  secondary,  not  a  primary  tumor,  the  primary  disease 
being  a  mixed  enchondroma  of  the  shoulder. 


Fig.  165. 


Spindle-cell  sarcoma.    (After  H.  Arnott ) 
Thin  section,  showing  in  the  centre  groups  of  cells  divided  transversely. 


4.  The  scirrhous  or  fibrous  cancer  is  so  very  rare  that  Dr.  West  has 
never  recognized  a  clear  case  during  life,  and  Paget  has  not  met  with 
it.  Rokitansky  thus  describes  it,  deducing  his  description,  as  he  ad- 
mits, from  a  very  few  observations :  "  On  a  careful  examination,  one 
may  discover,  in  the  midst  of  the  tissue  of  the  portio-vaginalis,  another 
structure  recognizable  by  the  different  shade  of  white  of  the  fibres  com- 
posing it,  and  which,  though  closely  packed,  intersect  each  other  in 
every  imaginable  direction ;  while  the  small  interstices  between  them 
are  filled  by  a  transparent  matter,  of  a  pale  yellowish-red  or  grayish 
color.  This  new  structure  is  infiltrated  into  the  uterine  substance 
without  any  distinct  limits,  extending  further  in  one  part  than  in  an- 
other, and  here  and  there  heaped  up  in  greater  quantity,  thus  produc- 
ing the  enlargement  of  the  portio-vaginalis,  the  uneven  nodulated 
character,  and  the  well-known  induration  of  its  substance." 

There  is  a  form  of  intractable  ulceration  of  the  os  and  cervix  uteri, 
which  most  authorities  refer  to  ejiithelial  cancer,  but  which  some  regard 
as  of  tubercular  nature.  The  tubercular  ulcerations  are  thus  described 
by  Robei't :  "  They  may  be  recognized  by  their  excavated  base,  their 
grayish  appearance,  and  the  presence  of  caseous  matter  in  the  midst  of 
the  muco-purulent  discharges  which  come  from  the  interior  of  the  cer- 
vix ;  also  by  the  presence  in  the  cervix  of  tumors  of  uncertain  size, 


COERODIls'G    ULCER MYXOMA.  715 

rounded  form,  at  first  firm,  and  with  no  change  of  color,  afterwards 
soft,  whitish,  yielding  to  the  pressure  of  the  fingers,  and  giving  an 
indistinct  sense  of  fluctuation.  These  tumors  are  formed  by  the  tuber- 
cular matter  still  in  a  crude  state,  or  in  course  of  softening.  These 
scrofulous  ulcerations  are  almost  always  accompanied  by  considerable 
engorgement  of  the  cervix  uteri."  On  the  other  hand,  under  the  mi- 
croscope, the  softened  matter  is  found  not  to  consist  of  the  elements  of 
tubercle,  but  of  epithelial  cells  similar  to  those  of  the  uterine  mucous 
membrane,  while  the  indurated  callous  structure  which  forms  the  base 
of  the  ulcer  is  composed  of  a  mixture  of  fibro-plastic  and  epidermoid 
materials.  Robin  says  this  kind  of  ulcer  is  to  the  uterus  what  lupus 
or  cancroid  ulcers  are  to  the  face.  I^ebert,  Hannover,  and  Dr.  Charles 
West  support  the  testimony  of  Robin. 

The  corroding  ulcer  of  Dr.  John  Clarke,  or  rodent  ulcer.  Opportu- 
nities for  observing  this  form  of  ulcer  on  the  cervix  uteri  are  exceed- 
ingly rare.  But  the  observations  that  have  been  made  justify  the 
conclusion  that  the  disease,  when  affecting  the  uterus,  is  similar  to  the 
rodent  ulcer  of  the  face  or  other  parts.  Its  aspect,  rate,  and  mode  of 
progress  are  unlike  those  of  cancer,  while  neither  cancer-cells  nor 
epithelium  formations  are  present  in  the  adjacent  tissues.  It  begins 
at  the  mucous  membrane  covering  the  os  uteri,  involving  the  w^hole 
circumference  of  the  os,  and  utterly  destroying  both  it  and  the  subjacent 
parts,  but  there  is  no  thickening,  hardness,  or  deposit  of  new  matter 
in  the  vicinity.  Unlike  cancer,  the  rodent  ulcer  may  continue  for 
years,  without  causing  any  very  formidable  symptoms. 

Lancereaux  describes  four  forms  of  malignant  or  quasi-malignant 
disease  of  the  uterus :  epithelioma,  carcinoma,  sarcoma,  and  myxoma. 
The  myxoma  he  compares  with  the  hydatiforra  degeneration  of  the 
chorion.  In  one  case  he  describes,  the  body  only  was  affected ;  the 
cavity  was  enlarged,  filled  with  mammillary  projections  compressed 
against  each  other,  and  implanted  in  the  mucous  membrane  by  a  kind 
of  pedicle.  They  resembled  the  columnse  earners  of  the  heart.  Others, 
smaller  and  more  rounded,  were  as  big  as  an  almond  or  champignon. 
They  were  generally  soft,  collapsed  under  pressure  of  the  finger,  giving 
issue  to  a  little  thick  juice.  They  were  yellowish-white,  or  blackish 
from  small  blood-extravasations.  These  masses,  constituted  by  rounded 
cells,  fusiform  and  refracting,  separated  by  an  amorphous,  hyaline  sub- 
stance, inclosed  large  and  numerous  vessels,  remarkable  for  the  delicacy 
of  their  coats.     The  subject  died  of  pneumonia. 

The  frequency  with  which  malignant  disease  invades  the  cervix  of 
the  uterus  in  preference  to  the  body  seems  to  be  overrated.  Cases  are 
really  not  infrequent  in  which  disease  running  a  malignant  course  is 
met  with  in  the  body,  the  cervix  remaining  quite  unaffected.  All  the 
forms  of  malignant  disease  may  begin  in  the  body.  I  am  not  in  a 
position  to  affirm  which  is  the  most  frequent:  but  I  am  inclined  to 
think  that  the  medullary  or  encephaloid  form  is  the  most  common. 
When  the  body  is  primarily  aifected,  distress  is  usually  manifested  at 
an  earlier  stage.  Hemorrhages  especially  are  frequent  and  profuse. 
Pain  is  more  intense  and  persistent.  The  morbid  tissue  projects  into 
the  enlarged  cavity  in  irregular  masses,  sometimes  of  polypoid  shape. 


716  CANCER  OF  THE  UTERUS. 

but  seldom  being  fairly  pedunculate.  They  are  usually  sessile  on  broad 
bases.  They  bleed  profusely  on  the  slightest  touch.  Probably  in  the 
case  of  epitheliomatous  growths  there  is  a  stage  when  the  disease  is 
mainly  superficial,  the  substratum  in  the  muscular  wall  of  the  uterus 
being  still  but  slight.  Some  forms  of  the  "  fungosities  "  or  "  carnosities/' 
referred  to  in  the  chapter  on  "Endometritis/'  are,  I  have  no  doubt,  of 
epitheliomatous  nature.  Indeed,  Mr.  Arnott  has  examined  for  me 
some  specimens  I  have  scraped  off  from  the  living  uterus.  This  tem- 
porary superficial  limitation  is  extremely  important  to  recognize,  since 
it  offers  the  prospect,  if  not  of  cure,  at  any  rate  of  temporary  relief  by 
surgical  treatment. 

In  these  cases  the  body  of  the  uterus  is  commonly  enlarged  to  about 
double  the  natural  size,  from  its  walls  being  thickened.  The  patient 
being  under  chloroform,  the  finger  will  generally  pass  through  the 
cervix,  and  thus  we  can  explore  the  cavity  of  the  uterus  by  direct 
touch.  The  cavity  is  generally  shorter  than  normal  ;  the  walls  are 
apart ;  they  form  a  rigid  hollow  globe ;  the  finger  feels  a  soft  pulpy 
mass  lining  the  whole  cavity  ;  portions  are  easily  detached  by  pressure 
or  scraping  with  the  nail.  These  brought  away  look  to  the  naked  eye 
like  boiled  sago  in  red  currant  jelly.  Some  bleeding  invariably  attends 
this  examination.  Portions  of  the  diseased  tissue  often  are  discharged 
spontaneously,  and  thus  reveal  the  nature  of,  the  affection. 

Cancer  of  the  body  of  the  uterus  is  sometimes  secondary,  having  been 
derived  from  primary  affection  of  the  ovary.  Benporath  and  I^iebmann 
(Monatsschr.  f.  Geburtsk.,  1865)  describe  a  case  of  fibroids  of  the  uterus 
which  became  affected  with  cancerous  infiltration,  proceeding  from 
primary  cancer  of  the  vagina. 

The  lymphatic  glands  of  the  pelvis,  and  especially  those  which  sur- 
round the  uterus,  are  frequently  the  seat  of  cancerous  extension.  The 
invasion  proceeds  step  by  step,  successively  catching  the  glands  situated 
b}'  the  lumbar  vertebrae,  and  following  the  course  of  the  large  vessels, 
which  may  be  compressed  or  ulcerated.  Sometimes  the  inguinal  glands 
become  cancerous.  This  is  especially  the  case  when  the  disease  has 
attacked  the  vagina  and  vulva.  I  have  described  two  cases  in  which 
the  glands  in  remote  parts  of  the  body  were  also  affected.  It  may, 
however,  have  happened  that,  in  these  cases,  the  enlargement  and  in- 
duration were  due  to  irritation  from  the  absorption  of  the  fluid  element 
(the  cancerous  ichor)  of  cancer,  and  not  to  the  actual  sjiread  of  cancer- 
cells.  It  is  remarkable  that  in  one  of  these  cases,  marked  general  im- 
provement, with  diminution  of  the  glandular  swellings,  followed  upon 
the  attainment  of  a  healthier  condition  of  the  local  disease. 

As  to  the  frequency  with  which  the  glands  are  implicated,  the  most 
accurate  information  is  supplied  by  Henry  Arnott  (Path.  Trans.,  1870), 
who  examined  57  cases  of  cancer  in  the  Middlesex  Hospital.  There 
were  no  secondary  growths  in  34.  The  lymphatic  glands  were  involved 
in  20;  in  11  the  viscera  contained  secondary  growths;  of  these,  5  in 
ovaries,  3  in  liver,  2  lungs,  1  heart,  1  both  breasts,  1  peritoneum. 

In  22  the  microscopic  characters  were  clearly  made  out.  True  cancer 
12,  epithelioma  8,  spindle-cell  sarcoma  2.  In  both  cases  of  spindle- 
ccll  sarcoma,  the  disease  appeared  elsewhere  also,  L  e.,  in  pelvic  glands. 


PATHOLOGY.  717 

Of  the  8  epitheliomata  the  taint  extended  in  three  instances — (1)  to 
ovary  and  pelvic  and  lumbar  glands;  (2)  broad  ligament;  (3)  to 
lumbar  glands.  Of  the  12  true  cancers,  9  spread,  pelvic  or  lumbar 
glands  being  affected  in  7,  one  or  both  ovaries  in  4,  liver  in  1,  heart 
and  lungs  in  1. 

Why  cancer  in  all  its  forms  so  frequently  affects  the  lower  segment 
of  the  uterus  seems  to  be  accounted  for  by  the  fact  that  the  neck  and 
mouth  of  the  organ,  besides  being  extremely  vascular,  are  subject  to 
constant  motion,  and  are  very  largely  supplied  with  lymphatics.  It 
is  not  surprising,  says  H.  Arnott,  that  any  morbid  infiltration  tending 
to  ra2:)id  cell-growth  and  early  decay  should  lead  to  extensive  ulceration 
on  a  free  surface  in  constant  friction  against  an  opposed  similar  surface. 
Such  irritation  would  be  certain  in  all  cases  to  set  up  inflammatory 
processes  in  their  immediate  neighborhood,  and  the  naturally  irritating 
secretions  of  both  uterus  and  vagina,  tainted  by  the  new  addition, 
would  speedily  cause  the  spread  of  such  malignant  destruction  in  the 
manner  so  commonly  Matnessed.  It  should  also  be  remembered  that 
it  is  in  the  cervix  principally  that  chronic  inflammation,  hyperplasia, 
hypertrophy,  and  all  those  changes  take  place  which  follow  upon  labor. 
These  changes  may  be  the  starting-point  for  malignant  cell-growth, 
and  may  explain  the  comparative  frequency  with  which  this  affects 
women  who  have  borne  children. 

The  duration  of  cancer  is  illustrated  to  a  certain  extent  by  the  ob- 
servations of  H.  Arnott.  Dating  from  the  time  when  the  patient  first 
complained  of  distressing  symptoms — generally  a  flooding — the  average 
duration  of  57  cases  of  all  kinds  of  cancer  until  the  fatal  termination, 
was  77.1  weeks.  The  average  duration  of  the  cases  of  true  cancer  was 
53.8  weeks,  of  the  cases  of  epithelioma  82.7  weeks ;  the  two  cases  of 
sarcoma  lived  for  a  considerable  period. 

Cancer  of  the  uterus  is  sometimes  unfortunately  complicated  with 
pregnancy.  This  condition  renders  the  cancerous  growth  more  active ; 
and,  since  the  child  must  traverse  the  diseased  tissues,  labor  can  only 
be  effected  at  the  expense  of  dangerous  or  even  fatal  violence.  Dr. 
West  has  collected  74  cases  of  cancer  complicating  labor.  In  41  death 
soon  followed  labor ;  33  recovered  from  the  effects  of  labor ;  47  of  the 
children  were  lost. 

Dr.  Cook  (Path.  Trans.,  vol.  x)  exhibited  some  foetal  bones  found  in 
the  cavity  of  the  uterus  of  a  women  who  died  of  cancer.  Nine  months 
before  she  had  had  an  abortion.  The  uterus  was  large,  firm,  and  infil- 
trated with  a  white  granular  deposit.  The  cervix  was  completely* 
destroyed  by  an  extensive  slough.  The  extrusion  of  the  dead  embryo 
was  probably  prevented  by  a  cancerous  slough  in  the  vagina. 

The  Modes  in  which  Cancer  Terminates. — Apart  from  the  faint  pros-, 
pect  of  an  occasional  cure  from  treatment  under  favorable  circumstances, 
the  history  of  cancer  of  the  uterus  is  scarcely  brightened  by  a  ray  of 
hope.     But  to  faith  in  the  possibility  of  cure,  spontaneous  or  surgical, 
the  practitioner,  not  less  than  the  patient,  should  nevertheless  adhere. 

Spontaneous  cure  is  not  absolutely  impossible.  On  rare  occasions 
nature  has  accomplished  the  elimination  of  the  disease.  It  may  be 
said  that  there  is  a  continuous  attempt  to  throw  off  the  diseased  tissues 


718  CANCER  OF  THE  UTERUS. 

manifested  in  the  ulceration  which  occurs  in  the  advanced  stages.  This 
ulceration  consists  really  in  necrosis  or  mortification  of  the  superficial 
strata  of  the  cancerous  mass.  Dr.  Habit  relates  a  case  which  is  not 
altogether  unique.  Cancerous  matter  united  the  uterus  to  the  sur- 
rounding structures ;  the  vagina  was  filled  with  large  granulations 
and  fungous  growths.  Gradually  all  was  replaced  by  firm  cicatrix,  and 
the  uterus  could  no  longer  be  felt.  I  have  seen  a  case  in  which  a  similar 
process  was  partially  carried  out.  I  saw  from  time  to  time  a  woman 
who  was  affected  with  epithelioma  of  the  uterus  invading  the  roof  of 
the  vagina.  During  two  years  the  disease  w^as  progressive,  and  at  the 
end  of  that  time  seemed  to  be  rapidly  marching  to  a  fatal  end  by  ex- 
haustion, "when  a  large  mass  of  solid  tissue  infiltrated  with  cancerous 
disease  was  expelled.  Temporary  relief  was  felt.  At  a  later  period 
another  mass  as  large  as  the  first  was  cast,  with  renewed  temporary 
improvement,  but  a  large  cloaca  was  left,  into  which,  the  bladder  and 
rectum  opened;  and  I  have  no  doubt  long  before  this  partial  elimina- 
tion took  place,  the  lumbar  glands  had  been  invaded,  so  that  the  attempt 
at  spontaneous  cure  came  too  late. 

I  am  acquainted  with  another  case  which  may  be  open  to  question 
as  to  accuracy  of  diagnosis,  but  in  which  there  seems  to  me  to  be  reason 
to  believe  that  nature  effected  a  ciire.  Dr.  Newman,  of  Stamford,  was 
called  to  deliver  a  woman  in  labor  at  term,  delivery  being  obstructed 
by  an  abnormal  state  of  the  lower  segment  of  the  uterus.  The  normal 
tissue  of  the  uterus  was  replaced  by  a  very  unusual  hardness,  circular, 
uniform,  and  infiltrated  apparently  into  the  body  of  the  uterus  in  every 
direction  for  more  than  an  inch  in  extent.  The  cervix  was  eaten  away 
at  its  posterior  lip  into  a  deep  sulcus  ;  the  anterior  lip  was  as  hard  as. 
the  posterior,  irregular,  with  a  hard  nodulated  or  granulated  feeling  to 
the  finger.  The  os  felt  to  the  finger  as  if  it  were  an  opening  cut  out  of 
a  piece  of  cartilage,  perfectly  hard  and  resisting.  The  deep  sulcus,  the 
small  narrow  orifice,  and  the  thickened  anterior  lip,  throughout  denuded 
of  epithelium,  granulated,  and  furnishing  watery  oozing  and  sanious 
fluid,  seen  through  the  speculum,  left  no  doubt  that  the  case  was  one  of 
extensive  epithelioma  of  the  cervix  and  lower  part  of  the  uterus.  Two 
medical  friends.  Dr.  Ashforth  and  Mr.  He  ward,  carefully  examined 
the  case  and  concurred  in  Dr.  Xewman's  opinion.  The  Caesarian  section 
was  performed  to  remove  the  child.  The  mother  made  a  good  recovery. 
Last  year  being  again  pregnant.  Dr.  Newman  brought  her  to  town  to 
consult  with  me  as  to  the  course  to  be  pursued.  This  was  five  years 
after  the  delivery  just  narrated.  I  found  no  hardness  or  disease  of  the 
uterus.  We  agreed  to  let  the  pregnancy  take  its  course.  She  has  since 
been  delivered  with  little  assistance. 

It  may  be  conjectured  that  the  disease  was  not  cancer,  but  pelvic 
cellulitis.  But  on  the  other  hand,  the  evidence  that  it  was  cancer 
must  be  admitted  to  be  strong.  I  think  it  probable  that  the  pro- 
tracted labor  caused  such  an  amount  of  pressure  upon  the  morbid  mass 
as  to  produce  mortification  and  elimination. 

Dr.  Gallard  relates  (Union  Medicale,  1873)  a  case  in  which  the  en- 
tire uterus  was  expelled.  The  woman  wais  thirty-five  years  old  ;  the 
cervix  uteri  had  been  destroyed  by  cancer.     She  died  twelve  days  after- 


SPONTANEOUS     CURE,  719 

wards  from  peritonitis,  produced  by  the  contact  of  virus.  The  ex- 
pelled organ  was  carefully  examined  and  laid  before  the  Toulouse 
Medical  Society  in  1844. 

In  the  breast  the  course  of  cancer  is  more  open  to  observation ;  and 
here  undoubted  cases  of  spontaneous  cure  have  occurred.  Thus  Samuel 
Cooper  says  (Surgical  Dictionary),  "  One  young  woman  whom  I  at- 
tended for  a  cancerous  womb,  of  which  she  died,  had  an  aged  mother, 
who  had  suffered  from  cancer  of  each  breast,  but  had  latterly  been 
freed  from  the  disease  by  a  sloughing  process  ;  an  event  which  is  un- 
common, but  does  now  and  then  happen." 

A  common  mode  by  which  cancer  kills  is  by  inducing  exhaustion 
by  hemorrhagic  and  other  discharges ;  but  I  believe  that  other  pro- 
cesses conduce  to  the  fatal  issue.  There  is  almost  always  some  degree 
of  blood-poisoning.  And  this  comes  from  several  sources.  The  constant 
necrosis  and  ulceration  of  the  surface  of  the  diseased  mass  produce  a  gran- 
ulating vascular  surface  capable  of  absorbing  the  foul  ichor  which  bathes 
it ;  hence  ichorrhsemia.  Another  source  is  the  intestine.  Whenever 
cancer  has  proceeded  so  far  that  the  disease  has  caught  the  rectum,  ob- 
struction either  by  direct  compression,  or  by  interference  with  the  con- 
tractility of  the  muscular  coat,  leads  to  accumulation  and  partial  reten- 
tion of  fecal  matter  above.  This  induces  retrograde  dilatation  of  the 
intestinal  canal.  The  arrest  of  the  excrementitious  matters  in  the  di- 
lated bowel  is  followed  by  decomposition,  marked  by  distressing  flatus. 
Absorption  of  the  products  of  the  decomposed  and  retained  fecal  mat- 
ter takes  place.  Hence  another  form  of  blood-poisoning  to  which  I 
propose  to  give  the  name  of  copraemia.  It  is  greatly  to  this  that  the 
unhealthy  and  dirty-sallow  aspect  of  the  skin  is  due.  Cancer  may 
also  lead  to  fatal  ileus,  either  by  pressure  or  through  adhesions,  the 
result  of  the  peritoneal  inflammations  which  so  often  complicate  this 
disease. 

The  cancer-juice  is  in  many  cases  also  absorbed.  Evidence  of  this  is 
seen  in  the  infection  of  the  glands,  which  arrest  probably  only  a  por- 
tion of  the  fluid  in  its  transit  towards  the  general  circulation. 

Added  to  these  sources  of  blood-degradation,  there  is,  of  course, 
impaired  nutrition  to  accelerate  the  sinking  from  exhaustion. 

Some  women  die  of  actual  starvation.  Thus  I  have  known  cases 
of  uterine  cancer  in  which  the  hemorrhage  had  ceased,  and  in  which, 
from  inability  to  bear  any  food,  gradual  exhaustion  carried  off  the 
patients. 

Combined  with  these  causes  of  exhaustion  and  blood-poisoning, 
there  is  not  infrequently  such  a  retrograde  impairment  of  the  urinary 
apparatus  that  the  function  of  the  kidney  is  obstructed,  and  urinsemia 
also  occurs.  The  obstruction  beginning  in  the  bladder,  leads  succes- 
sively to  dilatation  of  the  ureters,  of  the  pelvis  of  the  kidney,  and  to 
atrophy  of  its  secreting  structure  ;  that  is,  to  hydronephrosis. 

The  circulation  is  yet  exposed  to  another  invasion.  The  vessels 
which  supply  the  uterus  run  through  the  broad  ligaments  into  the  neck 
of  the  uterus  on  either  side,  just  at  the  very  seat  of  election  of  cancer. 
When  the  disease  has  extended  into  the  connective  tissue  around  these 
vessels,  they  undergo  mechanical  compression ;  they  become  imbedded 


720  CANCER  OF  THE  UTERUS. 

in  a  dense  mass  which  c[uite  destroys  that  freedom  of  motion  and  elas- 
ticity which  characterize  the  healthy  vessels ;  they  are  converted  into 
rigid  tubes,  and  these  tubes  are  often  contorted,  and  encroached  upon 
by  projections  which  destroy  the  evenness  of  their  bores.  The  veins 
especially  suffer  from  these  changes.  The  blood  moving  with  diflfi- 
culty,  subject  to  frequent  delays,  easily  coagulates.  Hence  venous 
thrombosis,  which  is  probably  often  promoted  by  the  entrance  into 
the  blood  of  irritating  matter  which  has  the  property  of  causing  coag- 
ulation. This  obstruction  to  the  local  circulation  is  probably  a  main 
agent  in  producing  those  profuse  hemorrhages  from  the  free  surface  of 
the  disease  which  are  so  characteristic  of  cancer.  But  it  entails  other 
consequences.  The  first  is  progressive  thrombosis  in  the  veins  extend- 
ing to  the  internal  iliacs,  then  to  the  common  iliacs,  even  to  the  vena 
cava.  The  obstruction  of  the  common  iliac  vein  of  course  leads  to  ob- 
struction of  the  external  iliac,  and  the  effect  of  this,  concurrently  with 
the  necessary  clogging  of  the  lymphatics,  is  seen  in  phlegmasia  dolens 
of  the  leg.  And  no  doubt  the  lymphatics  are  aifected  like  the  veins. 
When  it  comes  to  this  the  end  is  not  far  off.  As  far  as  I  know  phleg- 
masia dolens  from  cancer  of  the  uterus  is  incurable.  The  sufferer  lin- 
gers for  a  few  weeks,  perhaps,  until  life  is  extinguished  by  advancing 
exhaustion,  unless  another  event,  embolism,  occur  to  precipitate  the 
fatal  issue.  In  some  cases  I  have  seen  the  iliac  veins  and  some  inches 
of  the  vena  cava  filled  with  a  dirty,  soft,  pulpy  clot,  resembling  un- 
healthy pus.  It  cannot  be  a  subject  of  surprise  if  matter  so  degraded 
easily  gives  rise  to  detached  fragments,  ^vhich  are  carried  into  the  heart 
and  thence  into  the  pulmonary  arteries.  I  have  lately  seen  a  lady  die 
of  phlegmasia  dolens-  consecutive  on  cancer  of  the  uterus,  and  embol- 
ism of  the  brain  inducing  hemiplegia. 

I  have  seen  several  sudden  deaths  in  women  suffering  from  cancer  of 
the  uterus.  They  have  occurred  under  circumstances  which  involved 
an  unusual  physical  exertion  or  emotion.  In  one  such  case,  that  of  a 
woman  recently  admitted  into  St.  Thomas's  Hospital,  I  found  condi- 
tions which,  to  my  mind,  explained  the  catastrophe.  The  pelvic  organs 
were  matted  together  by  the  cancerous  disease,  the  lumbar  glands  were 
infiltrated  and  enlarged,  and  these,  with  similar  infiltration  of  tlie  con- 
nective tissue,  surrounded  and  fixed  the  aorta  and  vena  cava  nearly  as 
high  as  the  diaphragm.  The  elasticity  of  these  vessels  was  thus  quite 
destroyed.  The  aorta  was  virtually  a  rigid  tube;  and  the  vein  was 
bulged  in  in  many  places  by  the  projecting  masses  outside.  In  the  left 
heart  were  large  decolorized  fibrin-clots.  Under  such  conditions,  the 
circulation  cannot  go  on  well.  Under  the  slightest  increase  of  impulse 
of  the  heart,  a  difficulty  would  arise  in  the  transmission  of  the  volume 
of  the  blood  projected  by  it  into  the  narrowed  rigid  aorta;  this  would 
react  upon  the  feeble  heart,  cause  a  struggle  and  asphyxia.  In  this 
particular  case  there  were  no  emboli  or  thrombi  found  in  the  pulmonary 
arteries. 

In  many  cases,  concurrently  or  not  with  the  consolidation  of  the 
broad  ligaments,  peritonitis  supervenes,  cither  being  the  immediate 
cause  of  death,  or  leading  to  ulterior  trouble  by  matting  together  the 


DIAGNOSIS.  721 

adjoining  organs,  and  thus  impeding  them  in  the  execution  of  their 
functions. 

Death,  more  or  less  sudden,  may  be  caused  by  the  shock  attending 
perforation  into  the  peritoneal  cavity.  Dr.  Priestly  showed  to  the 
Obstetrical  Society  (1870)  a  specimen  of  carcinoma  of  the  body  of  the 
uterus.  The  prominent  symptoms  had  been  profuse  and  irregular 
hemorrhages,  alternating  with  abundant  discharges  intensely  fetid. 
Death  took  place  with  symptoms  of  collapse.  It  was  found  that  per- 
foration had  taken  place  through  the  anterior  wall  of  the  uterus. 

Peritonitis  may  be  excited  without  perforation  of  the  peritoneum. 
In  this  case  it  is  probably  caused  by  the  irritation  of  the  cancer  growth 
in  the  structures  immediately  invested  by  the  peritoneum.  The  peri- 
tonitis in  these  cases  is  of  a  chronic"  kind,  and  conduces  to  a  fatal  issue 
in  a  remote  or  secondary  manner,  as  by  causing  obstruction  to  the 
action  of  the  intestines.  But  sometimes  the  ulcerative  process  eats 
through  the  peritoneum,  and  thus  sets  up  inflammation  in  this  mem- 
brane, which  may  be  the  immediate  cause  of  death. 

It  may  also  be  excited  by  a  process  of  local  septicaemia  and  throm- 
bosis, extending  along  the  veins  and  lymphatics,  coming  from  the 
morbid  mass  towards  the  peritoneal  surface  of  the  uterus,  or  in  the 
broad  ligaments. 

Secondary  tumors  may  arise  in  various  parts  and  interfere  with  the 
functions  of  important  organs ;  for  example,  such  a  tumor  may  obstruct 
the  hepatic  duct,  and  induce  jaundice,  disorganization  of  the  liver,  and 
thus  death ;  or  cancerous  deposits,  embolic  or  developed  in  some  other 
way,  may  form  in  the  brain  or  lungs,  and  so  harass  these  organs  as  to 
bring  life  to  a  stand. 

The  Diagnosis. — The  distinctive  indications  are  different  in  the  cases 
where  cancer  attacks  the  cervix,  and  in  those  where  it  attacks  the  body 
of  the  uterus. 

The  diagnosis  of  cancer  of  the  uterus  in  the  early  stages  is  beset 
with  difficulties.  The  opportunities  of  studying  the  disease  at  this 
stage  are  so  rare,  that,  even  when  seen,  for  want  of  knowledge  of  its 
characteristics,  it  may  escape  recognition.  Thirty  years  ago  there  can 
be  no  doubt  that  cases  of  simple  hypertrophy  or  inflammatory  engorge- 
ment were  not  infrequently  assumed  to  be  cancer ;  and  credit  was  asked 
for  having  cured  them.  Duparcque,  Lisfranc,  Ashwell,  and  Mont- 
gomery certainly  fell  into  this  error.  And,  notwithstanding  the  more 
accurate  knowledge  since  extended,  mainly  through  the  researches  of 
Teallier  and  Henry  Bennet,  of  the  consequences  of  inflammation  of  the 
cervix  uteri,  enabling  us  in  most  cases  to  eliminate  these  conditions,  the 
clinical  observer  is  still  liable  to  mistakes. 

The  characters  assumed  by  the  os  and  cervix  uteri  during  the  earlier 
stages  of  medullary  cancer  are  less  familiar  and  therefore  less  clearly 
denned  than  those  which  mark  the  later  stages.  At  first,  whilst  strictly 
localized  in  the  cervix,  the  cervix  is  larger  than  natural,  and  one  or 
more  bumps  of  the  size  of  half  a  nut,  hard,  resisting  the  finger,  quite 
insensible,  may  be  found  on  the  lips  of  the  os  uteri.  There  is  often, 
also,  some  puckering  of  the  os.  At  this  stage  the  mobility  of  the 
uterus  is  not  impaired.     Through  the   speculum  these  bumps  show  a 

46 


722  CANCER  OF  THE  UTERUS. 

violet-red  tint,  quite  distinct  from  the  rosy  tint  of  the  rest  of  the  cer- 
vix. Up  to  this  time,  and  indeed  long  after,  the  patient  may  still  ex- 
hibit the  outward  signs  of  florid  health. 

A  characteristic  form  of  malignant  disease  of  the  os  uteri  in  the 
earliest  stage  is  due  to  the  extension  or  spreading  of  the  superficies  of 
the  OS,  whilst  the  cervix  above  remains  the  same.  This  gives  the  figure 
of  a  mushroom  to  the  part.  It  is  true  that  ordinary  hypertrophic 
elongation  of  the  cervix  begins  somewhat  in  a  similar  way ;  but  the 
"cancer-mushroom"  is  distinguished  by  its  more  complete  resemblance 
to  the  mushroom  shape,  the  spreading  proceeding  all  round  the  os;  and 
by  the  everted  os  of  hypertrophy  presenting  a  smoother  surface.  Mal- 
gaigne  describes  the  "  Champignons  cancereux." 

In  forming  the  diagnosis  of  cancer,  the  speculum  and  sound  are 
commonly  useless — except  in  the  very  earliest  stage — and  may  be 
injurious.  The  tissues  seem  brittle;  they  break  under  the  distension 
caused  by  the  speculum ;  they  often  bleed  freely  even  on  the  slightest 
touch  of  the  finger;  and  if  the  speculum  is  introduced  greater  injury 
is  caused,  and  the  eifused  blood  obscures  what  might  otherwise  be  seen. 
The  finger  by  the  vagina  and  rectum  tells  all  that  is  necessary  to  es- 
tablish the  melancholy  diagnosis. 

I  believe  the  sign  that  most  frequently  arrests  attention  in  the  first 
place  is  hemorrhage ;  and  then,  when  we  examine,  we  find  the  disease 
far  advanced.  In  several  cases  the  first  thing  to  suggest  the  presence 
of  disease  has  been  hemorrhage  on  sexual  intercourse.  Pain  of  a 
marked  character,  even  the  stabbing,  lancinating  pain  described  as  al- 
most pathognomonic  of  cancer,  is  often  absent  for  a  long  time.  So 
long  as  the  disease  is  limited  to  the  cervix  uteri  there  is  commonly  little 
pain.  But  when  it  has  extended  beyond,  and  especially  in  the  last 
stages,  pain  is  often  constant  and  agonizing,  destroying  rest.  Pain  and 
swelling  above  the  groin  in  the  iliac  region  show  extension  of  the  dis- 
ease to  the  lymj)hatic  glands  and  peritonitis.  Broca  and  Cornil  have 
shown  that  where  women  have  long  suffered  extreme  pain  in  the  thighs, 
legs,  and  nates,  there  has  been  either  an  epithelial  neoplasm  or  hy2)er- 
trophy  of  the  cellular  tissue  of  the  neurilemma  of  the  sciatic  or  crural 
nerves,  and  that  some  nerve-tubules  are  partially  affected,  the  medul- 
lary substance  being  transformed  into  granular  fat-molecules.  The 
pains  have  a  radiating  character,  starting  as  it  were  from  the  centre  of 
the  disease,  and  shooting  to  the  sacrum,  vertebral  column,  loins,  groins, 
and  thighs. 

In  the  earlier  stages,  no  particular  odor  is  perceived,  but  when  ulcer- 
ation has  begun,  an  odor,  penetrating  and  offensive,  is  almost  certain 
to  be  emitted.  It  is  so  peculiar  that  frequently  by  it  the  presence  of  a 
cancerous  patient  is  made  known.  It  clings  tenaciously  to  the  linen 
and  to  the  examining  finger. 

In  advanced  cancer  the  aspect  of  the  patient  is  often  enough  to  excite 
a  strong  suspicion  of  the  nature  of  the  disease.  Emaciation  is  general, 
but  not  constant.  The  skin  acquires  a  dirty  straw  tint,  indicative  of  a 
profound  alteration  in  the  properties  of  the  blood,  and  of  impaired 
nutrition.  It  is  true  that  a  very  similar  tint  is  often  seen  in  women 
who  have  long  been  draining  from  polypus  or  inversion  of  the  uterus. 


DIAGNOSIS.  723 

But  internal  examination  at  once  clears  up  the  diagnosis.  The  altera- 
tion referred  to  is  due  to  three  causes :  the  influence  of  the  cancerous 
cachexia,  which,  as  Becquerel  has  shown,  first  destroys  the  globules, 
and  afterwards  diminishes  the  quantity  of  albumen ;  to  the  hemor- 
rhages, which  very  quickly  diminish  the  globules ;  and  to  the  serous 
discharges.  Thus  the  water  of  the  blood  increases ;  the  globules  and 
the  albumen  diminish.  The  cancerous  cachexia  is  sooner  or  later  fol- 
lowed by  hectic  or  irritative  fever. 

Sooner  or  later  bladder-distress  almost  always  comes.  The  first 
symptom  to  arrest  attention  is  often  dysuria  or  partial  incontinence  of 
urine,  so  that  examining  the  bladder  we  find  to  our  surprise,  cancer  of 
the  uterus.  At  a  later  stage  the  urine  may  all  escape  by  a  fistulous 
opening  into  the  bladder  near  the  cervix  uteri.  I  have  lately  had  a 
case  in  St.  Thomas's  Hospital  Avhere  a  valvular  cicatrized  opening  into 
the  bladder  near  the  os  uteri  was  the  only  opening  found,  the  ordinary 
meatus  urinarius  being  undiscoverable. 

Cancer,  when  limited  to  the  vaginal-portion,  that  is,  whilst  the  uterus 
still  retains  its  mobility,  has  to  be  distinguished  from  the  various  con- 
ditions of  inflammation,  hypertrophy,  and  non-malignant  tumors  of 
this  part.  The  condition  most  likely  to  give  rise  to  error  is  hyper- 
trophy of  the  follicles  of  the  os  uteri  from  occlusion.  This  condition 
produces  small  nodular  projections,  the  centres  of  angry,  vivid  conges- 
tion. They  differ  from  commencing  cancer,  in  showing  a  whitish, 
translucent  centre,  due  to  the  retained  mucous  secretion ;  and  in  being 
curable  by  puncture.  But  it  sometimes  takes  time  for  observation  be- 
fore a  sure  diagnosis  can  be  formed.  Perhaps  the  best  training  for  the 
eye  to  the  recognition  of  early  cancer  of  the  os  uteri  is  obtained  by  the 
observation  of  the  appearance  of  commencing  cancer  at  the  mucous 
outlets  of  the  body,  for  example  at  the  vulva,  anus,  mouth,  nose,  and 
eyes. 

When  cancer  has  spread  from  the  vaginal-portion  to  the  roof  of  the 
vagina,  the  cellular  tissue  between  the  cervix  and  bladder  to  the  broad 
ligaments,  the  uterus  will  almost  necessarily  be  set  fast.  The  primary 
disease  of  the  cervix  will  be  partly  obscured  by  the  secondary  sur- 
rounding disease.  It  is  in  this  condition  chiefly  liable  to  be  mistaken 
for  perimetric  inflammation  and  inflammatory  deposits.  An  important 
distinction,  often  available,  lies  in  this :  in  cancer  the  disease  is  in  the 
cervix  itself;  in  perimetritis  it  is  around  the  cervix.  Some  cases  of 
fibroid  tumors  distorting  the  cervix,  and  fixing  the  uterus  in  the  pel- 
vis, may  give  rise  to  error. 

In  both  cases  the  vaginal-portion  is  commonly  brought  down  into  a 
lower  plane;  it  is  more  easily  reached.  But  it  is  especially  in  advanced 
cancer  that  the  diseased  mass  is  often  carried  so  low  down  that  the  finger 
scarcely  penetrating  the  vulva  strikes  at  once  upon  it.  And  there  are 
other  points  of  distinction.  By  the  time  that  the  uterus  is  set  fast  by 
cancer,  other  characteristics  are  usually  pronounced,  as  hemorrhage, 
foul  discharges,  pain.  Perimetric  inflammation,  too,  has  a  different 
history ;  it  dates  from  an  epoch  pretty  clearly  defined,  beginning  with 
labor,  abortion,  or  menstruation. 

Foul-smelling,  irritating  discharge  occasions  great  anxiety,  because 


.724  CANCER    OF    THE    UTERUS. 

it  is  a  popular  belief  that  these  characters  are  peculiar  to  malignant  dis- 
ease. But  they  are,  in  truth,  acquired  by  the  retention  of  the  discharge 
in  the  vagina. 

When  cancer  begins  in  the  body  of  the  uterus,  the  mobility  of  the 
organ  may  not  be  interfered  with  until  very  late  in  the  course  of  the 
disease.  It  may  be  mistaken  for  endometritis,  with  or  without  subin- 
volution ;  for  hypertrophy  with  engorgement;  for  fibroid  or  other  non- 
malignant  tumors,  especially  those  of  the  submucous  or  polypoid  kind. 
One  point  of  distinction,  sometimes  available,  consists  in  the  origin  of 
the  disease.  Fibroid  tumors  begin  in  the  muscular  wall  of  the  uterus, 
cancer  more  often  on  the  mucous  surface. 

A  feature  valuable  in  the  diagnosis  of  intra-uterine  cancer  is  the  fol- 
lowing :  The  morbid  tissue  projecting  into  the  cavity  shortens  it,  so 
that  the  sound  may  penetrate  two  inches  only,  or  less ;  at  the  same  time 
the  walls  become  incapable  of  collapse,  they  remain  rigid,  are  kept  apart, 
forming  a  spherical  hollow,  rough  inside.  When  we  get  this  condition 
we  may  conclude  that  the  disease  has  laid  hold  of  the  walls  of  the  uterus, 
altering  their  physical  property,  destroying  contractility.  This  is  one 
cause  of  congestion  and  bleeding.  If  the  uterine  walls  are  felt  yielding, 
if  the  anterior  wall  can  be  flattened  upon  the  posterior,  there  is  rarely 
cancer  of  the  body  of  the  uterus.  Chronic  metritis  may  induce  a  some- 
what similar  condition,  but  it  will  be  less  marked  than  that  produced 
by  cancer. 

Pain  is  usually  more  intense,  and  comes  on  earlier  in  the  cases  where 
cancer  invades  the  body  of  the  uterus.  This  pain  is,  to  a  certain  extent, 
diagnostic.  Metritis  and  non-malignant  tumors  are  not  usually  attended 
by  pain  so  agonizing  or  so  unremitting.  But  still  even  this  symptom 
is  not  constant.  For  example,  I  saw  in  consultation  with  Dr.  Byass 
and  Dr.  Saunders  a  lady  aged  about  fifty,  a  pluripara,  who  had  ceased 
menstruating  for  two  years.  For  three  years  she  had  been  subject  to 
constant  sero-sanguineous  discharge,  and  her  health  had  become  im- 
paired, I  found  the  vaginal-portion  of  normal  size,  os  closed ;  the 
uterus  was  movable,  and  its  body  was  enlarged,  firm,  regular  in  form. 
The  diagnosis  was  entered  interrogatively  as  intra-uterine  polypus, 
fibroid  or  malignant  disease  of  the  body  of  the  uterus.  I  recommended 
dilatation  by  tents  to  explore  the  interior.  Four  months  after  this  she 
died,  and  Dr.  Saunders  sent  me  the  following  account :  "  It  turned  out 
to  be  encephaloid  cancer  of  the  body  of  the  womb.  The  following  cir- 
cumstances are  remarkable  :  its  duration  of  nearly  four  years ;  the  ab- 
sence of  any  intense  pain ;  the  absence  of  hemorrhage,  the  only  dis- 
charge being  considerable  quantities  of  blood-stained  serum  of  oiFensive 
odor,  and  this  suddenly  stopped  about  a  month  before  death  ;  the  per- 
fect integrity  of  the  os  up  to  the  very  last,  there  being  slight  thicken- 
ing, and  its  contractile  power  retained.  At  the  post-mortem  the  whole 
of  the  fundus  uteri  was  in  a  broken-down  condition,  exhibiting  the 
signs  of  encephaloid,  the  microscope  subsequently  verifying  them.  The 
patient  died  from  asthma,  there  being  hardly  any  prominent  signs  of 
the  disease  u]>  to  the  last.  I  diagnosed,  however,  from  the  general 
cachexia  and  increasing  weakness  without  an  explainable  cause.  There 
were  no  secondary  deposits  in  other  organs ;  the  liver  was,  however,  in 


PROGNOSIS    AND    DURATION.  725 

a  state  of  amyloid  degeneration."  Pain  is  due  partly  to  the  stretching 
of  the  muscular  fibre,  partly  to  the  contractile  efforts  aroused  by  the 
parasitic  growth,  partly  by  the  pressure  of  the  enlarged  uterus  upon 
surrounding  structures,  partly  to  the  invasion  of  surrounding  structures 
by  the  disease,  and  partly  by  the  nerves  themselves  being  affected  by 
it.  In  some  cases  reflex  irritation  produces  pain  in  distant  parts,  and 
vomiting  is  not  infrequent,  especially  in  the  advanced  stages. 

After  lasting  some  time,  the  cervical  canal  will  commonly  undergo 
some  dilatation. 

But  the  surest  test  of  intra-uterine  cancer  is  to  bring  away  small 
fragments  of  the  superficial  projections  from  the  cavity,  and  subject  them 
to  microscopical  examination.  In  describing  endometritis,  we  have 
seen  that  there  are  cases  in  which  small  pisiform  excrescences  exist, 
whose  nature,  or  rather  whose  history,  is  for  a  time  a  source  of  doubt. 
In  endometritis  or  metritis  not  complicated  with  cancer,  the  walls  of 
the  uterus  are  less  rigid. 

To  facilitate  this  preliminary  dilatation  of  the  cervix,  it  may  be 
effected  by  tents.  Then  Sims's  curette  (see  Fig.  97,  p.  476)  may  be  in- 
troduced and  a  shred  easily  scraped  off.  This  dilatation  will  also  per- 
mit of  digital  exploration.  The  patient  under  chloroform,  the  hand 
may,  if  necessary,  be  passed  into  the  vagina,  the  finger  will  then  easily 
survey  the  interior  of  the  uterus,  and  recognize  the  pulpy  projections 
of  malignant  disease.  There  is  the  less  objection  to  this  proceeding, 
because  dilatation  effected  for  diagnosis  is  useful  for  treatment. 

As  a  guide  to  treatment  as  well  as  to  prognosis,  it  is  important  to 
distinguish  the  hind  of  malignant  disease.  Thus  outbreaks  of  can- 
cerous disease  are  comparatively  frequently  met  with  in  neighboring 
glands  or  in  remote  viscera.  This  furnishes  a  strong  argument  against 
hasty  operative  interference  with  a  view  to  extirpating  the  disease. 
These  secondary  foci  being  greatly  more  common  with  true  cancer  and 
sarcoma  than  with  epithelioma,  the  microscopic  examination  of  the 
morbid  structure  becomes  of  great  importance  in  determining  on  a  line 
of  treatment. 

"  The  scrofulous  ulcerations  are  almost  always  accompanied  by  con- 
siderable engorgement  of  the  cervix  uteri."  On  the  other  hand,  under 
the  microscope,  the  softened  matter  is  found  not  to  consist  of  the 
elements  of  tubercle,  but  of  epithelial  cells  similar  to  those  of  the 
uterine  mucous  membrane,  while  the  indurated  callous  structure  which 
forms  the  base  of  the  ulcer  is  formed  of  a  mixture  of  fibro-plastic  and 
epidermoid  materials.  Robin  says  this  kind  of  ulcer  is  to  the  uterus 
what  lupus  or  cancroid  ulcers  are  to  the  face.  Lebert,  Hannover,  and 
Dr.  Charles  West  support  the  testimony  of  Robin. 

The  'prognosis  may  in  general  terms  be  said  to  be  settled  when  the 
diagnosis  is  determined.  It  is  henceforth  limited  to  the  questions,  How 
long  will  the  patient  survive  ?  In  what  manner  and  to  what  degree 
will  she  suffer?  Of  course,  if  we  adopt  the  more  hopeful  doctrine 
that  at  the  initial  stage  the  disease  is  a  local  one,  the  prognosis  will  be 
favorable  in  cases  where  the  diagnosis  is  formed  whilst  the  disease 
appears  to  be  isolated  in  the  vaginal -portion  in  such  a  manner  as  to 
admit  of  complete  amputation  or  destruction.     But  it  is  precisely  in 


726  CANCEE  OF  THE  UTERUS. 

these  cases  that  diagnosis  is   liable  to  be  fallacious ;    and  erroneous 
diagnosis  will  vitiate  the  prognosis. 

What  is  the  dwalion  of  cancer  of  the  uterus  ?  As  the  early  stages 
so  often  escape  detection,  it  is  not  easy  to  determine  the  total  duration. 
It  is  probable  that  the  stage  before  ulceration,  of  limitation  to  the 
cervix,  may  last  for  some  months,  even  two  or  three  years.  When 
ulceration  has  begun,  the  downhill  course  is  often  rapid. 

Prognosis  will  be  affected  by  treatment.  For  example,  if  the  dis- 
ease be  allowed  to  run  its  course  uninterrupted,  the  fatal  termination 
will  in  many  cases  come  at  an  earlier  date  than  in  those  cases  where 
judicious  surgical  treatment  has  been  adopted.  It  is  very  difficult  to 
set  out  this  comparative  statement  in  figures.  But  a  comparison  of 
cases  seems  to  justify  certain  deductions.  Thus  we  take  two  cases  of 
cauliflower  excrescences,  apparently  chiefly  limited  to  the  vaginal-por- 
tion, and  amputate  as  far  as  we  can  the  diseased  mass  in  the  one  case, 
and  avoid  surgical  treatment  in  the  other.  We  may  pretty  confidently 
predict  that  in  the  second  case  hemorrhage,  watery  discharges,  and 
general  infection  will  destroy  the  patient  in  a  few  months.  We  may 
with  equal  confidence  predict  that,  if  the  diseased  mass  be  fairly 
removed,  the  destructive  processes  will  be  arrested  for  a  time,  and  that 
the  patient's  life  will  be  prolonged.  I  have  known  a  patient  recover 
so  far  that  she  and  her  friends  believed  recovery  to  be  complete ;  she 
became  pregnant  three  months  after  operation,  and  was  delivered  by 
artificial  induction  of  labor  at  the  end  of  eight  months'  gestation.  At 
this  time  there  was  return  of  the  disease,  but  her  general  health  was 
good.  At  the  time  of  the  operation  she  was  so  reduced  by  hemor- 
rhages, and  the  disease  M^as  so  progressive,  that  it  seemed  highly 
probable  that  she  would  sink  within  three  months. 

So  in  some  cases  of  superficial  malignant  disease,  whether  of  the 
cervix  uteri  or  of  the  interior  of  the  body  of  the  uterus,  the  removal 
or  alteration  of  the  diseased  surface  by  actual  cautery,  by  nitric, 
chromic  or  acetic  acid,  or  by  scraping,  has  stopped  bleeding  and  decom- 
position, and  thus  cut  off  a  source  of  blood-infection.  Patients  so 
treated  have  improved  considerably,  and  it  cannot  be  doubted  have 
had  their  lives  prolonged,  and  made  for  a  time  more  endurable. 

In  not  a  few  cases  of  epithelioma  in  which  no  decided  local  treat- 
ment has  been  employed,  life  has  been  prolonged  several  years  after 
the  disease  has  been  recognized ;  and  we  have  no  means  of  estimating 
how  long  it  had  existed  before  recognition.  In  cases  of  this  kind  the 
disease  is  not  uniformly  progressive.  It  seems  to  proceed  by  stages 
with  intervals  of  halt.  For  a  time,  seldom  indeed  very  protracted,  the 
disease  may  even  appear  to  be  so  completely  arrested  that  the  patient 
is  tempted  to  accept  tlie  reprieve  as  a  promise  of  cure.  If  one  of  these 
delusive  halts  coincide  with  a  new  treatment,  especially  if  backed  up 
by  the  bold  assurances  of  a  "  cancer-curer,"  she  eagerly  interprets  all 
things  according  to  her  wishes,  and  builds  up  upon  this  transitory 
foundation  the  most  confident  hope  of  recovery. 

Tliese  alternations  of  progress  and  arrest  suggest  another  reflection 
which  it  is  very  important  to  bear  in  mind  when  we  are  called  upon 
to  pronounce  a  prognosis.     If  we  express  an  adverse  opinion  without 


TREATMENT.  727 

such  qualification  as  the  uncertain  march  of  the  disease  demands,  if, 
straightway  on  forming  a  diagnosis  of  cancer,  we  declare  the  nature  of 
the  disease  and  venture  to  foretell  a  brief  duration  of  life,  especially  if 
we  assign  a  specified  limit,  we  commit  a  twofold  error.  One  error 
inflicts  needless  misery  on  the  patient,  the  other  falls  back  with  not 
undeserved  retaliation  upon  ourselves.  To  utter  the  word  "  cancer," 
and  to  say  that  the  sufferer  has  only  a  short  time  to  live,  is  literally  to 
pronounce  sentence  of  death  unmitigated  by  the  hope  of  reprieve. 
Such  a  sentence,  whenever  it  comes,  even  after  long  and  advancing 
disease,  even  after  sufferings  to  escape  from  which  death  may  have 
been  often  silently  invoked,  falls  like  a  crushing  blow,  adding  to  phys- 
ical torture  the  agony  of  despair. 

Cancer  differs  in  this  respect  from  phthisis  in  its  effect  upon  the 
mind.  The  buoyant  hope  that  to  the  last  so  often  sustains  the  subject 
of  phthisis,  that  flatters  him  with  the  belief  that  the  doctors  are  mis- 
taken in  his  case,  that  there  is  nothing  serious  in  it,  has  little  or  no 
place  in  cancer.  It  may  be  confidently  said  that,  whereas  many  persons 
struck  with  incurable  phthisis,  refuse  to  believe  in  this  reality,  few  or  no 
persons  struck  with  cancer  long  indulge  in  such  a  dream.  INIany  who 
have  no  sign  of  cancer  are  ready  to  believe  that  they  are  suffering  from 
the  disease ;  few  or  none  who  are  really  suffering  from  it  fail  to  recognize 
their  condition.  And  this  they  will  do,  although  the  physician  may 
never  have  uttered  the  word. 

The  error  that  rebounds  upon  the  physician  who  is  too  hasty  to  con- 
demn is  this :  Not  long  after  he  has  passed  sentence  the  patient  unex- 
pectedly improves,  or  thinks  she  does;  one  of  those  delusive  halts  is 
reached,  and  "another  opinion,"  possibly  less  skilled  and  less  honest 
than  his  own,  encourages  the  welcome  belief.  For  the. time  he  is  dis- 
credited; to  the  patient's  own  injury  probably  he  is  discarded.  And 
when  at  length  the  inexorable  disease  resumes  its  fatal  course,  he  will 
hardly  be  forgiven.  And  as  an  additional  caution  against  an  absolute 
and  uncompromising  condemnation,  humility  should  dictate  the  possi- 
bility of  error  in  diagnosis. 

The  proper  course  in  framing  an  opinion,  one  dictated  by  truthful- 
ness, the  first  law,  by  the  modesty  which  is  conscious  of  fallibility, 
and  tempered  by  mercy,  is  to  explain  that  the  case  is  only  to  a  certain 
extent  amenable  to  treatment,  that,  whilst  some  improvement  may  be 
expected,  it  is  likely  to  be  temporary  only,  and  that  the  usual  course  of 
the  disease  when  once  established  is  to  shorten  life.  The  patient  will 
almost  invariably  draw  the  true  significance  from  such  expressions. 
She  will  believe  that  she  has  cancer.  But  she  will  be  grateful  for 
having  been  spared  the  cruel  word. 

The  treatment  may  most  conveniently  be  discussed  under  the  leading 
heads  of  curative  and  palliative.  The  first  question  which  always  chal- 
lenges attention  is  that  of  curability.  In  the  great  majority  of  cases 
when  first  seen,  unhappily,  this  is  quickly  answered  in  the  negative. 
The  disease  has  gone  too  far,  or  it  has  assumed  a  form  which  precludes 
the  idea  of  removing  it.  But  in  a  certain  number  of  cases,  the  disease 
is  sufficiently  isolated  in  the  vaginal-portion  to  justify  the  attempt;  and 
in  some  cases  of  epithelioma  of  the  cavity  of  the  uterus,  where  the  dis- 


728  CANCER  OF  THE  UTERUS. 

ease  is  ascertained  to  be  superficial,  an  attempt  to  remove  or  destroy 
the  diseased  surface  may  also  be  made.  The  epithelioma  or  cauliflower 
excrescence  of  the  vaginal-portion  offers  the  best  prospect  of  cure  by 
amputation.  The  best  test  of  the  fitness  for  amputation,  I  think,  is 
the  freedom  in  mobility  of  the  uterus.  Amputation  was  at  one  time  a 
mode  of  dealing  with  cancer  of  the  uterus  much  in  vogue.  But  it 
would  be  useless  to  invoke  the  experiences  of  the  past  generation  of 
surgeons  as  to  the  efficacy  of  their  practice,  because  error  of  diagnosis 
vitiates  it  to  an  unknown  extent.  It  is,  however,  well  to  cite  the  ex- 
cellent summary  Samuel  Cooper  gives  of  this  subject  down  to  his  time. 

"Modern  experience  proves,"  he  says,  ''that  when  cancer,  or  rather 
scirrhus,  is  confined  to  the  neck  of  the  uterus,  it  wdll  sometimes  admit 
of  being  successfully  removed  by  excision.  The  cervix  uteri,  in  the 
healthy  state,  projects  from  three  to  six  lines  into  the  vagina;  but  M. 
Lisfranc  has  known  it  make  no  projection  at  all.  The  vagina  around 
it  is  thin,  and  in  contact,  on  one  side,  with  the  bladder,  and,  on  the 
other,  with  the  rectum ;  while  upwards  it  is  continuous  with  the  proper 
substance  of  the  uterus.  The  vagina  may  be  detached  from  the  cervix 
uteri  to  the  extent  of  more  than  half  an  inch,  without  any  risk  of  open- 
ing the  cul-de-sac  of  the  peritoneum,  which  separates  it  from  the  blad- 
der; but  since  the  latter  viscus  adheres  very  intimately  to  its  anterior 
surface,  it  might  then  be  reached  by  the  instrument.  Behind,  the 
peritoneum  not  only  covers  the  corresponding  surface  of  the  uterus, 
but  also  descends  over  the  vagina,  to  form  what  M.  Velpeau  terms  the 
rectogenital  excavation ;  so  that,  on  this  side,  the  knife,  if  carried  only 
a  few  lines  would  open  the  peritoneum.  M.  Velpeau  considers  it 
erroneous  then  to  say  that  there  is  a  space  of  eight  lines  in  front,  and 
ten  behind,  between  the  upper  edge  of  the  cervix  uteri  and  the  serous 
membrane  of  the  abdomen.  The  distance  is  stated  by  M.  Malgaigne 
to  vary,  according  to  the  greater  or  lesser  projection  of  the  cervix.  M. 
Malgaigne  also  states,  that  the  vagina  may  always  be  detached  from 
the  cervix  to  the  extent  of  more  than  half  an  inch  in  front,  without 
hazard  of  wounding  the  peritoneum;  but,  behind,  the  vagina  ascends 
further,  and  there  is  less  space  between  it  and  the  peritoneum.  It  may 
be  added,  that  no  very  large  arteries,  or  veins,  are  distributed  to  the 
neck  of  the  womb.  (See  Velpeau,  'Nouv.  Elem.  de  Med.  Oper.,'  t.  iii, 
p.  620;  Malgaigne,  'Man.  de  Med.  Oper.,'  p.  747,  ed.  2.) 

"  According  to  Baudelocque,  the  excision  of  the  cervix  uteri  was  fii'st 
suggested  in  1780,  by  Lauvariot.  M.  Tarral  even  ascribes  it  to  Tulpius ; 
but  the  tumors  which  the  latter  took  away  were,  according  to  M,  Vel- 
peau, evidently  polypi.  Lazzari,  who  puts  in  a  claim  for  Monteggia, 
is  also  believed  to  have  made  a  similar  mistake ;  nor  has  M.  Velpeau 
been  able  to  satisfy  himself  that  the  operation  was  ever  performed  by 
Andre-de-la-Craix  and  Lapeyronie,  as  M.  Tarral  represents.  Troisberg 
recommended  it,  however,  in  1787;  and  as  a  critical  writer  observes, 
sometimes  the  cervix  uteri  was  removed  accidentally  with  the  knife  by 
ignorant  persons,  who  mistook  it  for  a  polypus.  (See  Edin.  Med.  and 
Surg.  Journ.,  No.  103,  p.  377.)  Professor  Osiander,  of  Gottingen, 
first  executed  the  operation  in  1801,  on  a  widow,  whose  vagina  was 
filled  by  a  very  vascular  fetid  fungus,  as  large  as  a  child's  head,  grow- 


TREATMENT.  729 

ing  from  the  orifice  of  the  womb.  By  means  of  Smellie's  forceps,  the 
fungus  was  drawn  down  ;  but  it  broke  oft',  and  a  tremendous  hemorrhage 
ensued.  The  operator,  without  loss  of  time,  introduced  several  crooked 
needles,  armed  with  strong  ligatures,  through  the  bottom  of  the  vagina, 
and  body  of  the  uterus,  until  they  emerged  at  the  os  tincse.  These 
ligatures  served  to  draw  down  the  uterus,  and  retain  it  near  the  mouth 
of  the  vagina.  Qsiander  then  introduced  a  bistoury  above  the  scirrhous 
portion,  and  divided  the  uterus  exactly  in  the  horizontal  direction  :  for 
an  instant  the  bleeding  was  profuse,  but  it  was  quickly  stopped  by 
means  of  a  sponge,  saturated  with  styptics.  In  about  a  month  the 
woman  recovered.  Osiander  afterwards  performed  eight  similar  opera- 
tions upon  difterent  patients,  all  of  whom  are  reported  to  have  experi- 
enced a  cure.  The  observations  of  Osiander  were  no  sooner  promulgated 
in  France,  than  M.  Dupuytren  adopted  the  new  operation,  and  made 
numerous  trials  of  it.  M.  Recamier  followed  Dupuytren ;  so  that,  by 
1815,  the  excision  of  the  cervix  uteri  had  become  in  France  a  common 
operation.  However,  it  remained  for  M.  Lisfranc  to  extend  the  prac- 
tice, and  to  convince  the  most  incredulous  of  the  little  danger  resulting 
from  it.  (M.  Yelpeau,  '  Nouv.  El6m.  de  Med.  Op6r.,'  t.  iii,  p.  615.) 
Dupuytren  also  performed  the  operation  eight  times ;  but,  instead  of 
employing  the  ligatures  and  knife,  as  Osiander  did,  he  drew  down  the 
uterus  with  hook  forceps,  and  divided  it  above  the  scirrhous  part  with 
curved  knives  and  scissors.  One  of  the  patients,  on  whom  Dupuytren 
operated,  had  a  return  of  the  disease,  and  submitted  to  a  second  opera- 
tion with  no  better  result ;  but  was  afterwards  efiPectually  cured  by  the 
application  of  caustic,  with  the  aid  of  the  speculum  invented  by  M.  Rec- 
amier. 

"  Even  with  regard  to  the  excision  of  the  cervix  uteri,  it  is  perfectly 
manifest  to  me  that  many  of  the  cases  in  which  it  was  performed  were 
not  truly  cancerous.  Doubts  may  be  entertained,  I  think,  whether 
the  enormous  tumor  removed  in  the  very  first  instance  of  such  opera- 
tion by  Osiander,  was  really  a  cancerous  aftection.  Several  of  the  cases 
operated  upon  in  Paris  were  decidedly  not  of  this  character.  On  this 
point  I  fully  agree  with  Dr.  Brown,  an  eye-witness,  who  remarks  : 
'  While  I  admit  the  facility  with  which  such  a  measure  may  be  accom- 
plished, I  must  be  permitted  to  doubt  its  necessity  in  some  of  the  cases 
related.  The  second  and  third  were,  in  my  opinion,  such  aifections  as 
would  have  yielded  to  common  local  and  constitutional  measures,  and 
would,  I  have  no  doubt,  have  been  so  treated  by  British  surgeons,  and 
perhaps  by  a  few  of  our  French  brethren.'  M.  Velpeau  would  not 
absolutely  renounce  the  operation.  'It  is  better,'  says  he,  'to  try  it 
than  abandon  the  woman  to  a  certain  death,  whenever  the  disease 
leaves  a  hope  that  the  whole  of  it  may  be  removed.'  (See  '  Nouv. 
Elem.  de.  Med.  Oper.,'  t.  iii,  p.  616.) 

"In  1828  M.  Lisfranc  had  performed  this  operation  on  thirty -six 
individuals,  as  is  stated,  for  Ganoer  uteri,  the  recognition  of  which  last 
declaration  as  a  positive  fact,  I  beg  to  observe,  is  a  matter  of  great  im- 
portance in  determining  the  merits  of  the  operation.  Of  the  thirty-six 
patients  thus  operated  upon,  'thirty  were  then  well,  three  dead,  and 
three  in  progress  of  recovery.     One  female,  operated  on  some  years 


730  CANCER    OF    THE    UTERUS. 

before,  had  since  become  pregnant,  and  recently  given  birth  to  twins. 
Lately,  at  the  Hdtel  Dieu,  the  entire  uterus  has  been  removed  by  M. 
Recamier ;  and  it  has  been  performed  at  La  Charite,  by  M.  Roux.  The 
patient  died  in  twenty-four  hours  after  the  operation.'  (See  '  Practical 
Formulary  of  the  Parisian  Hospitals,'  by  F.  S.  Katier,  p.  17.)  Lan- 
genbeck's  extirpation  of  the  entire  uterus,  by  cutting  through  nearly 
the  whole  of  the  linea  alba,  I  do  not  deem  it  necessary  to  detail,  as  it 
is  a  proceeding  which  I  would  never  recommend  to  be  imitated.  The 
poor  woman  experienced  the  same  fate  as  the  patient  of  M.  Recamier." 

In  Guy's  Museum  is  a  preparation  (No.  2259^*^)  of  the  vagina,  blad- 
der, rectum,  and  part  of  the  colon  of  a  woman,  from  whom  Dr.  Blundell 
a  year  before  death  had  removed  the  whole  uterus  for  cancer ;  disease 
invaded  rectum,  vagina,  &c.,  which  proved  fatal,  but  complete  union 
had  taken  place  between  the  pelvic  organs. 

Dr.  Wiltshire  has  recorded  (Brit.  Med.  Journ.,  1873),  a  case  in  which 
the  entire  uterus  was  accidentally  brought  away  or  sloughed  off  after 
an  operation,  which  consisted  in  scraping  the  diseased  surface.  Some 
cicatrization  of  the  vaginal  roof  took  place,  but  the  disease  returned. 

The  question  of  total  extirpation  of  the  uterus  is  one  that  scarcely 
admits  of  discussion.  The  circumstances  under  which  it  can  be  seriously 
contemplated  must  be  very  rare.  West  gives  a  table  of  recorded  cases 
of  total  extir]>ation  of  the  uterus  on  account  of  cancerous  disease.  In 
three  only  did  the  patient  survive  the  operation,  and  that  only  for  a 
month;  in  twenty-two  death  was  the  consequence. 

The  Selection  of  Cases  for  Amputation  of  the  Vaginal-portion. 

There  is  one  class  of  cases  in  \vhich  there  should  be  no  hesitation  in 
operating.  Just  as  the  surgeon  recognizes  the  propriety  of  amputating 
the.  breast  when  the  tumor  is  clearly  circumscribed,  movable,  and  no 
evidence  of  glandular  or  constitutional  infection  can  be  traced,  so  should 
he  when  similar  conditions  are  found  in  connection  with  cancer  of  the 
uterus.  If,  then,  we  find  the  uterus  freely  movable,  a  distinct  neck 
above  the  diseased  portion,  so  that  we  can  work  beyond  the  disease  in 
sound  tissue,  and  especially  if  the  disease  is  ascertained  by  microscope 
to  be  epitheliomatous  or  cancroid,  it  is  our  duty  to  amputate.  This 
should  be  done  whether  profuse  bleedings  occur  or  not.  The  plain 
course  is  to  anticipate  the  evils  which  will  certainly  come  if  we  leave 
things  alone.  In  such  cases  complete  cure  is  not  hopeless  ;  and  a  long 
respite  from  the  usual  effects  of  the  disease  may  be  confidently  looked 
for. 

In  another  class  of  cases  the  indication,  although  not  so  urgent,  is 
still  clear.  I  refer  to  those  cases  in  which  a  certain  degree  of  mobility 
of  the  uterus  remains,  but  in  which  the  base  of  the  disease  has  caught 
the  roof  of  the  vagina,  so  that  no  distinct  neck  or  demarcation  between 
healthy  and  diseased  tissue  can  be  made  out.  If  a  cauliflower-growth 
be  found  under  such  conditions,  and  be  the  source  of  hemorrhagic  and 
other  discharges,  the  ablation  of  so  much  of  the  diseased  mass  as  can 
well  be  surrounded  by  a  wire  should  be  attempted.     For  a  time,  at 


TREATMENT.  731 

least,  the  disease  will  be  stayed.  And  there  is  little  drawback  in  the 
shape  of  danger  from  the  operation  to  deter  from  its  performance. 

Where  the  vaginal-portion  is  attacked  by  medullary  cancer,  whilst 
in  the  stage  of  localization,  especially  in  the  mushroom  form,  the  uterus 
being  still  movable,  amputation  should  be  performed. 

The  fixing  of  the  uterus  being  due  in  almost  every  case  to  the  exten- 
sion of  the  disease  to  the  roof  of  the  vagina,  the  base  of  the  bladder, 
and  the  broad  ligaments,  is  evidence  that  it  has  passed  the  boundary 
where  it  can  be  reached  by  topical  remedies.  This  fixing  is  also,  I 
think,  in  many  cases  evidence  that  the  disease  has  invaded  the  lym- 
phatic vessels  and  glands,  a  still  further  discouragement  from  resort  to 
severe  surgical  treatment. 

When  the  operation  is  determined  upon,  we  have  to  consider  the  best 
mode  of  performing  it.  If  we  use  the  knife  or  scissors,  especial  care 
must  be  taken  to  avoid  opening  the  roof  of  the  vagina  behind,  and  per- 
forating the  retro-uterine  peritoneal  pouch.  To  obviate  this  accident, 
which  might  be  fatal,  the  vaginal-portion  of  the  uterus  must  be  care- 
fully isolated  from  the  vagina.  Dr.  Emmet  (Amer.  Journ.  of  Obstet- 
rics, 1869)  recommends  before  amputating  to  examine  M^hilst  the  patient 
is  placed  on  her  knees  and  elbows.  This,  by  favoring  gravitation, 
enables  us  to  note  the  exact  length  of  the  neck  more  accurately,  since, 
in  the  ordinary  posture,  the  neck  is  always  apparently  longer  from  pro- 
lapse of  the  uterus. 

But  since  it  is  almost  indispensable  to  the  use  of  the  knife  or  scissors 
that  the  whole  uterus  be  brought  low  down  near  the  vulva,  there  must 
always  be  danger  of  drawing  down  the  roof  of  the  vagina  and  the  retro- 
uterine peritoneal  pouch  with  it.  And  in  pursuance  of  the  object  to 
divide  the  cervix  as  high  as  possible  in  order  to  get  into  sound  tissue, 
the  danger  of  opening  this  pouch  is  serious.  It  constitutes  an  important 
objection  to  this  mode  of  operating.  The  objection  applies  also  to  the 
chain-6craseur,  which  is  very  apt  to  drag  in  the  peritoneal  pouch.  It 
applies  in  a  minor  degree  to  the  single-wire  ^craseur.  But  the  galvano- 
caustic  wire  is  almost  wholly  free  from  this  objection.  The  knife  and 
scissors,  and  the  single  wire  also,  entail  serious  danger  from  hemorrhage. 
To  arrest  this  it  may  be  possible  to  transfix  the  stump  with  a  curved 
needle  carrying  a  silver  wire.  But  the  best  way  is  to  use  the  actual 
cautery.  Copper  or  iron  cauteries  should  always  be  ready  when  this 
operation  is  undertaken. 

The  Operation  of  Amputating  the  Vaginal-'portion  of  the  Uterus  affected 
with  Malignant  Disease. — By  far  the  best  plan  is  to  use  the  galvano- 
caustic  wire.  The  patient  is  placed  under  chloroform  in  lithotomy 
position.  (See  p.  539.)  Sims's  speculum  is  introduced  to  keep  well 
back  the  perineum  and  posterior  wall  of  the  vagina.  An  assistant  on 
either  side  holds  open  the  lateral  and  anterior  walls  of  the  vagina  by 
small  retractors.  The  diseased  mass  thus  well  exposed  is  seized  as  far 
back  as  possible  with  a  vulsellum,  taking  care  not  to  tear  through  the 
fragile  structure.  The  mass  thus  brought  forward  near  the  vulva 
partly  by  gentle  traction,  but  more  by  the  firm  pressure  of  an  assistant's 
hand  upon  the  fundus  uteri  applied  above  the  symphysis  pubis,  is  then 
encircled  by  the  cold  platinum-wire  loop  passed  over  the  vulsellum. 


732  CANCER  OF  THE  UTERUS. 

The  loop  is  then  accurately  adjusted  by  the  finger  close  to  the  base  of 
the  mass,  and  therefore  close  to  the  roof  of  the  vagina.  The  slack  of 
the  wire  is  then  drawn  in,  so  that  the  loop,  tightly  embracing  the  root 
of  the  mass,  buries  itself  in  a  groove  all  round.  The  heat  now  being 
turned  on  burns  at  once  into  the  part  to  be  removed,  leaving  the  vagina 
quite  secure.  The  loop  is  gradually  screwed  up  as  the  burning  pro- 
ceeds. There  should  be  no  hurry  in  this  proceeding.  The  wire  being 
fine  is  rapidly  cooled  by  the  tissues;  it  must  have  time  to  renew  its 
heat,  so  that  the  substance  is  burnt  through,  not  cut  by  overtightening  the 
loop.  This  slow  process  gives  more  effectual  security  against  hemor- 
rhage, and  the  more  thorough  burning  of  the  surface  also  destroys  more 
effectually  the  remains  of  the  disease  in  the  stump.  When  the  wire  has 
burnt  its  way  through,  the  diseased  mass  is  removed  by  the  vulsellum, 
and  the  stump  is  carefully  examined.  A  series  of  concentric  rings 
mark  the  alternate  incandescent  and  cooler  states  of  the  wire  in  its 
progress.  The  bleeding  is  generally  arterial ;  one  or  more  fine  spirts 
may  be  seen.  These  I  have  always  succeeded  in  stanching  by  the 
actual  cautery  applied  by  the  galvanic  porcelain  button.  Light  swab- 
bing with  small  bits  of  sponge  soaked  in  iced  water  will  facilitate  the 
search  for  bleeding  points.  And  it  is  well  to  syringe  out  the  vagina 
by  playing  a  stream  of  iced  water  against  the  stump.  All  bleeding 
stopped,  the  vagina  should  be  firmly,  not  tightly,  packed  with  strips  of 
lint  soaked  in  carbolic  oil. 

The  after-dangers  are :  hemorrhage  and  retention  of  urine.  The 
first  may  be  arrested  for  a  time  by  further  plugging.  If  this  fail,  all 
plugs  should  be  removed,  and  the  stump  swabbed  with  perchloride 
or  persulphate  of  iron.  If  this  fail,  the  patient  must  be  placed  in 
lithotomy  position,  the  part  exposed  by  Sims's  speculum,  and  the  bleed- 
ing points  or  surface  seared  with  the  actual  cautery. 

The  carbolic  oil  dressing  may  be  removed  next  day,  and  a  single 
strip  of  lint  soaked  in  the  same  fluid  may  be  renewed  daily  for  a  week. 
After  this,  washing  out  with  Condy's  fluid,  or  weak  chloride  of  soda, 
will  be  useful.  The  surface  will  granulate  and  may  cicatrize  in  two 
or  three  weeks.  The  os  uteri  should  be  watched,  the  sound  being  oc- 
casionally passed  to  obviate  cicatricial  closure.  It  would  be  better  to 
abstain  henceforth  from  sexual  intercouse.  I  have  known  pregnancy 
to  occur  after  the  operation. 

The  stump,  or  granulating  surface,  may  be  sprinkled  every  three  or 
four  days  with  powdered  sulphate  of  zinc ;  or  if  any  sprouting  of  ma- 
lignant excrescence  show  itself,  it  may  be  kept  down  by  nitric  acid  or 
chromic  acid. 

As  already  stated,  amputation  is  sometimes  advisable  even  when 
there  is  no  reasonable  hope  that  the  operation  will  be  curative.  It  is 
quite  justified  in  some  cases  where  the  disease  has  extended  beyond  the 
vaginal-portion,  on  the  principle,  sanctioned  by  experience,  that  much 
good  is  effected  by  removing  the  most  active  portion  of  the  disease. 

Amputation  of  the  diseased  jiart  is  not  the  only  method  which  has 
been  proposed  and  practiced  with  the  view  of  curing  cancer.  As  in 
the  case  of  cancer  of  the  breast  various  caustics  have  been  employed : 
as  the  chloride  of  zinc,  Vienna  paste,  and  others.     Their  use  with  the 


TREATMENT.  733 

i 

view  of  destroying  the  diseased  mass,  is  now,  I  believe,  generally 
abandoned.  But  quite  recently  attempts  to  effect  a  radical  cure  by 
acting  upon  the  cancerous  growth  have  been  made  on  a  somewhat  dif- 
ferent principle.  Bromine  in  solution  has  been  recommended  by  Dr. 
Wynn  Williams  and  Dr.  Routli  to  be  applied  on  pledgets  of  lint  to 
the  diseased  surface.  In  some  cases  it  has  appeared  to  check  the 
disease  by  destroying  the  vitality  of  the  cancer-cell.  I  have  used  it 
extensively,  and  have  acquired  the  impression  that  disease  is  checked 
by  it.  And  there  is  no  doubt  that  it  is  most  effective  as  a  deodorant. 
Dr.  Broadbent  (1866)  recommended  acetic  acid  on  the  following  reason- 
ing; :  *'  Cancer  owes  its  malia-nancv  to  its  characteristic  structure 

To  alter  its  cells  is  to  put  an  end  to  their  power  of  dividing  and  mul- 
tiplying, and  consequently  to  arrest  the  growth  of  the  tumor.  In 
acetic  acid  we  have  an  agent  which  on  the  microscopic  slide  rapidly 
effects  important  changes  in  cells  of  every  kind,  dissolving  the  cell- 
wall  and  affecting  the  nucleus.  Not  coagulating  albumen,  it  may  dif- 
fuse itself  through  a  tumor,  and,  reaching  every  part  equally,  it  may 
probably  produce  similar  results  when  the  cells  are  in  situ."  He  injects 
equal  parts  of  acetic  acid  and  water.  I  do  not  know  how  far  this  pro- 
posal has  borne  the  test  of  clinical  experience.  But  it  seems  that  a 
hope  of  controlling  this  hitherto  intractable  disease  may  be  found  in 
its  further  pursuit.  In  one  case  in  which  I  repeated  the  application 
several  times,  phlegmasia  dolens  supervened.  The  patient  died.  Dr. 
Skene  (Amer.  Journ.  of  Obstet.,  1869)  inserted  arrows  of  chloride  of 
zinc  into  a  presumed  cancei"ous  affection  of  the  cervix  uteri ;  recovery 
resulted. 

The  following  passage  is  quoted  from  Cooper's  "  Surgical  Diction- 
ary : "  "  M.  Bayle  advocated  the  application  of  caustic  ;  and  his  advice 
was  founded  upon  the  fact  shown  by  pathological  anatomy,  that,  in 
the  early  stage  of  malignant  ulceration  of  this  part,  the  texture  of  the 
uterus  is  healthy  at  the  distance  of  two  or  three  lines  from  the  ulcer- 
ated surface.  The  patient  having  been  placed  in  the  right  position, 
and  the  speculum  introduced,  the  cancer  is  to  be  cleansed  with  dossils 
of  charpie.  If  the  surface  is  irregular,  or  the  seat  of  fungus  granula- 
tions, they  are  to  be  removed  with  curved  scissors,  or  a  sharp-edged 
kind  of  scoop  (Dupuytren).  In  this  manner,  indeed,  such  growths  may 
be  removed,  not  only  from  the  cervix,  but  from  the  interior  of  the 
uterus.  After  the  ulcer  has  been  cleaned,  a  roll  of  charpie  is  placed 
below  the  speculum,  in  order  to  protect  the  vagina  from  the  action  of 
the  caustic.  Then  the  caustic  is  applied,  either  the  arsenical  paste 
(Bayle),  or  the  pure  potash,  scraped  to  a  point,  and  fixed  in  a  ])orte- 
crayon ;  or  the  acid  nitrate  of  mercury,  with  which  lint  is  wetted  and 
conveyed  with  forceps  to  the  ulcer.  The  application  is  continued  for 
one  minute ;  then  copious  injections  of  tepid  Avater  are  employed  for 
the  removal  of  the  uncombined  particles  of  caustic ;  the  charpie  and 
specidum  are  withdrawn,  and  the  patient  put  into  a  warm  bath.  In 
about  four  or  six  days,  the  application  is  to  be  repeated,  and,  if  no  ill 
consequences  follow,  it  is  to  be  continued  at  short  intervals,  but  more 
and  more  lightly  each  time,  in  proportion  as  the  cure  advances.  (Lis- 
franc ;  also  Malgaigne,  Man.  de  Med.  Oper.,  p.  745,  ed.  2.") 


734  CANCER  OF  THE  UTEEUS. 

.  More  lately  chromic  acid,  nitric  acid,  and  strong  bromine  have  been 
used,  more  with  the  object  of  improving  the  superficial  condition  of 
the  diseased  surface,  and  of  retarding  the  march  of  the  disease,  than 
with  the  hope  of  cure. 

The  strong  disposition  to  thrombosis  in  the  pelvic  veins  in  cancer 
must  be  considered  in  dealing  with  cases  of  this  disease.  The  process 
may  be  started  by  the  remedies  employed,  and  thus  the  fatal  issue  may 
be  precipitated.  The  actual  cautery,  and  sulphuric  acid,  chromic  acid, 
perchloride  of  iron,  may  easily  cause  coagulation  of  the  blood  in  the 
vessels  near  the  surface  where  they  are  applied,  and  the  thrombi  so 
formed  may  spread  backwards.  The  rule  for  this  application  may,  I 
think,  be  laid  down  as  follows :  If  our  hope  is  to  cure  or  materially 
arrest  the  disease,  the  cauterizing  agent  must  be  applied  boldly  to  the 
disease  so  as  to  cause  a  slough  of  some  depth.  Now  this  cannot  be 
done  safely  if  the  disease  is  not  limited  to  the  cervix  or  the  lower  part 
of  the  uterus.  If  the  uterus  still  retain  its  mobility  we  have  a  reasona- 
ble assurance  that  the  disease  has  not  invaded  the  connective  tissue  and 
vessels  in  the  broad  ligaments  around  the  cervix.  Under  these  condi- 
tions the  caustics  may  be  freely  applied.  But  if  the  disease  have  ex- 
tended high  up  in  the  cervix  it  will  not  be  judicious  to  ap[)ly  the 
cauteries  named  so  freely  as  in  the  first  order  of  cases.  There  is, 
however,  another  indication  for  the  use  of  powerful  cauteries,  namely,  to 
arrest  profuse  hemorrhage  and  to  alter  the  character  of  the  discharges. 
This  may  commonly  be  most  effectually  done  by  a  superficial  applica- 
tion of  strong  chromic  acid,  nitric  acid,  or  perchloride  of  iron,  or  the 
actual  cautery.  The  bleeding  is  instantly  controlled  ;  and  a  thin  slough 
is  formed,  which,  when  thrown  off,  leaves  a  comparatively  healthy 
granulating  surface,  from  which  for  a  time  the  discharge  is  not  offen- 
sive. Considerable  constitutional  improvement  often  attends  the  local 
change. 

Mr.  Campbell  de  Morgan  says,^  in  reference  to  the  caustic  treatment 
of  cancer,  there  is  an  evil  attending  slow  cauterization,  namely,  that 
while  the  caustic  is  doing  its  work  increased  action  is  going  on  in  its 
neighborhood,  with  augmented  growth  of  that  part  of  the  cancer  which 
the  cancer  has  not  yet  reached.  If  the  whole  diseased  structure  be  not 
included  in  one  operation,  the  chances  are  that  the  undestroyed  tissue 
will  grow  with  greater  rapidity,  and  quickly  affect  distant  parts.  Still 
in  many  cases  the  method  by  gradual  cauterization  is  safe  and  effective. 
He  however  urges  it  as  an  absolute  rule  that  if  caustics  are  employed 
with  a  curative  intention,  they  must  be  used  fully  and  decisively. 

Latterly  Dr.  Routh  has  advocated  the  topical  use  of  pepsin.  Two 
successful  cases  had  been  published  by  Drs.  Tansini  and  Pagello 
(Gazetta  Med.  Lomb.,  1869).  Dr.  Routh  employs  this  agent  in  the 
following  way  :  He  first  destroys  the  surface  of  the  morbid  growth  by 
the  actual  cautery,  by  scraping,  by  bromine  or  other  agents.  A  raw 
surface  thus  obtained,  or  even  whilst  the  slough  still  remains,  he  applies 
the  gastric  juice  on  a  piece  of  lint  by  help  of  a  speculum.    This  is  covered 

1  "  The  Oric;in  of  Cancer  considered  with  Ileference  to  the  Treatment  of  the 
Disease."     1872. 


TEEATMENT.  735 

by  a  piece  of  oil-silk,  and  supported  by  a  plug.  This  should  be  done 
twice  a  day,  oftener  if  practicable.  The  digestive  property  of  the  pep- 
sin acts  powerfully  uj)on  the  morbid  structure.  He  reports  eases  in 
which  decided  benefit,  even  cure  resulted.  Of  course  the  objection  has 
been  raised  that  the  cases  were  not  cancer.  But  the  proper  course  it 
appears  to  me  is  to  pursue  the  treatment  in  cases  whose  nature  is  not 
doubtful.  I  have  seen  one  case  with  Dr.  Bantock  treated  in  this  way. 
I  was  satisfied  that  the  solvent  and  antiseptic  action  of  the  remedy 
upon  the  diseased  surface  M'as  great  and  beneficial.  All  objections  of 
a  theoretical  kind  must  ultimately  fall  before  the  evidence  of  clinical 
experience.  But  we  should  remember  that  pepsin  does  not  act  upon 
the  structure  of  the  living  stomach  ;  that  it  only  acts  vigorously  on 
dead  tissue.  At  one  of  the  first  meetings  of  the  Pathological  Society  I 
exhibited  the  stomach  of  a  woman,  a  great  part  of  which  had  been 
dissolved  after  death  by  its  own  gastric  juice.  John  Hunter's  observa- 
tions on  this  subject  are  well  known.  In  its  application  to  cancerous 
growths  as  advised  by  Dr.  Routh,  a  slough  is  first  formed.  This  will 
be  easily  dealt  with  by  the  pepsin.  But  further  observations  are 
desirable  to  try  how  far  the  pepsin  can  be  made  to  act  upon  the  deeper 
parts  of  the  living  morbid  substance. 

I  do  not  refer  to  the  use  of  arsenic  in  this  connection,  on  account  of 
the  danger  there  is  of  poisoning  the  system  when  applied  in  quantity 
sufficient  to  do  any  local  good  to  an  ulcerating  absorbing  surface. 

In  the  case  of  sarcoma  beginning  in  the  body  of  the  uterus,  if  we 
have  the  opportunity  of  recognizing  the  disease  in  its  early  stage  whilst 
limited  to  the  lining  membrane,  caustics  may  be  applied  decisively,  the 
cervix  uteri  having  been  previously  dilated  to  allow  this  to  be  done. 
But  this  form  of  malignant  disease  also  tends  to  advance  into  the  cervix, 
attacking  the  region  where  the  vessels  enter.  When  it  has  reached  tliis 
point,  and  especially  if  any  marked  amount  of  fixing  of  the  uterus 
exist,  cauteries  should  no  longer  be  applied  with  that  degree  of  severity 
which  is  indicated  when  their  curative  agency  is  looked  for. 

The  mode  of  proceeding  in  dealing  with  intra-uterine  cancer  is,  1st,  to 
dilate  the  cervix  with  one  or  more  laminaria-tents ;  2dly,  having  ascer- 
tained the  form  which  the  disease  assumes,  we  proceed,  if  there  are 
projecting  masses  more  or  less  polypoid,  to  shave  them  off  by  the  wire- 
ecraseur,  and  to  cauterize  the  surface  afterwards  with  the  actual  cautery 
or  nitric  acid,  or  if  there  are  small  excrescences  to  scrape  them  off' with 
Sims's  or  Becamier's  curette,  applying  nitric  acid  afterwards. 

The  actual  cautery  may  be  applied  by  an  iron  or  copper  olive-cautery 
through  the  cervix,  held  well  open  by  tenacula.  But  this  is  difficult  to 
accomplish  without  burning  the  cervical  canal  in  transit.  The  porce- 
lain olive  of  the  galvanic  apparatus  is  decidedly  superior.  It  can  be 
introduced  whilst  cold  to  the  very  spot  we  want  to  cauterize ;  and  the 
heat  being  turned  on  and  off"  at  will,  its  action  can  be  defined  with 
absolute  precision. 

To  apply  nitric  acid,  we  insert  a  tube  like  Atthill's  into  the  cervix 
to  serve  as  a  sheath  or  canula,  through  which  a  rod  carrying  cotton- 
wool steeped  in  the  acid  is  passed.  I  have  devised  a  funnel-shajoed 
tube  (Fig.  166,  p.  737),  mounted  on  a  stem  for  this  purpose,  which  I 


736  CANCER  OF  THE  UTERUS. 

find  more  convenient  than  Atthill's.  I  use  aSims's  duck-bill  speculum 
in  the  ordinary  way ;  then  the  cervical  tube  is  passed  into  its  place, 
and  the  stem  and  handle  keep  back  the  anterior  wall  of  the  vagina, 
aifording  ready  access  to  the  uterus.  The  instrument  has  also  the 
advantage  of  being  easily  withdrawn.  The  nitric  acid  swab  should  be 
pressed  firmly  down  upon  the  inner  surface  of  the  uterus,  so  as  to 
insure  decided  action  upon  the  morbid  surface.  The  action  is  quite 
superficial.     There  is  no  reason  to  apprehend  danger  from  its  use. 

The  palliative  treatment  of  cancer  consists  in  controlling  pain,  hemor- 
rhage, and  oiFensive  discharges ;  in  mitigating  the  distress  produced 
by  the  extension  of  the  disease  to  neighboring  organs,  especially  the 
bladder  and  rectum ;  and  in  meeting  as  best  we  may  the  constitutional 
deterioration. 

Pain  becomes  especially  exhaustive  in  the  latter  stages.  We  must 
have  recourse  to  opium  in  its  varied  forms,  in  pill,  draught,  suppository, 
vaginal  pessary,  subcutaneous  injection ;  to  conium,  belladonna,  Indian 
hemp,  chloral,  and  the  other  known  narcotics  and  sedatives.  The  local 
application  of  sedatives  has  been  extensively  tried  by  Simpson.  He 
played  streams  of  carbonic  acid,  and  of  chloroform  vapor  upon  the 
diseased  parts.  In  some  cases  benefit  resulted,  but  the  difficulty  is 
great  in  sustaining  the  action  of  these  remedies.  The  effect  is  but  tem- 
porary. The  application  of  cold  by  ice  or  freezing  mixtures  was  at  one 
time  urged  by  Dr.  James  Arnott,  in  the  belief  that  it  was  even  curative 
by  killing  the  diseased  tissue.  I  have  tried  the  application  of  cold  by 
means  of  the  ether-spray  in  several  cases.  It  produced  such  suffering 
that  I  have  abandoned  it. 

The  necessity  of  restraining  hemorrhage  when  profuse  becomes  urgent. 
Patients,  however,  often  affirm  that  they  have  felt  material  relief  after 
an  attack.  No  doubt  local  congestion  is  relieved  by  it,  and  the  habit 
of  free  bleeding  is  commonly  attended  by  a  habit  or  capacity  for  mak- 
ing blood  with  rapidity.  But  we  never  know  that  bleeding  will  not 
exceed  the  recuperative  capacity  of  the  system,  and  in  the  long  run 
repeated  losses  break  down  the  constitutional  powers.  Bleeding,  there- 
fore, must,  as  a  rule,  be  stopped.  Two  principles  call  for  attention. 
The  first  is  to  produce  such  a  change  in  the  condition  of  the  diseased 
part  as  will  lessen  its  morbid  activity  and  the  determination  of  blood 
to  it.  The  means  of  accomplishing  "this  are  included  in  the  curative 
treatment :  removal  of  the  diseased  mass  wholly  or  in  part,  by  cautery, 
by  knife  or  scraper,  and  the  securing  a  new  surface. 

The  second  principle  is  that  of  simple  hsemostasis.  This  is  carried 
out  by  the  direct  application  of  styptics.  Amongst  these  the  best  are 
chromic  acid,  nitric  acid,  perchloride  and  persulphate  of  iron.  To 
apply  these  effectually,  the  speculum  must  be  used.  Great  care  is 
necessary  in  passing  this  instrument,  as  the  fragility  of  the  morbid 
tissues  is  so  great  that  it  is  often  difficult  to  introduce  it  without  causing 
fresh  bleeding.  If  chromic  acid  be  used,  the  crystals  just  moistened 
with  water  is  the  best  form.  A  small  pledget  of  lint  or  cotton-wool 
steeped  in  this  is  then  pressed  gently  on  the  bleeding  surface.  It  turns 
the  part  bright  yellow,  chars  it,  and  generally  stops  the  bleeding  effec- 
tually.    The  superfluous  acid  can  be  washed  out  by  a  Higginson's 


TREATMENT. 


737 


syringe.     Nitric  acid  fuming  should  be  used  in  a  similar  manner.    The 
iron-styptics  should  also  be  used  very  strong. 

But  since  an  attack  of  hemorrhage  may  come  on  at  any  unforeseen 
time,  and  under  circumstances  which  preclude  skilled  assistance,  the 
patient  or  her  attendants  must  be  armed  with  appliances  and  instruc- 
tions to  meet  the  emergency.  As  a  temporary  expedient,  a  lump  of 
ice  may  be  passed  into  the  vagina.  But  a  more  cer- 
tain way  is  first  lightly  to  syringe  out  the  vagina  with 
cold  water,  then  to  introduce  by  means  of  my  plug- 
speculum  (see  p.  131)  a  pledget  of  cotton-wool  soaked 
in  the  strong  solution  of  perchloride  of  iron.  As  a 
rule,  the  plug  should  not  be  left  in  more  than  an 
hour.  Its  retention  is  often  accused  by  patients  of 
causing  heat,  distress,  and  of  provoking  return  of 
bleeding. 

The  control  of  the  offensive  watery  disharge  in- 
cludes the  use  of  deodorants  or  disinfectants.  Clean- 
liness is  the  first  thing  to  secure.  Syringing  with 
Condy's  solution  is  of  service.  But  since  the  frequent 
use  of  instruments  is  attended  with  more  than  incon- 
venience, injection  of  more  efficient  disinfectants  should 
be  resorted  to.  The  agent  which  has  given  me  the 
most  satisfaction  on  the  whole  is  acetate  of  lead.  The 
action  of  this  is  heemostatic,  deodorant,  and  sedative. 
It  has  often  struck  me  that  it  has  a  beneficial  effect 
upon  the  diseased  surface.  It  may  be  used  in  the  pro- 
portion of  one  drachm  to  a  pint  of  water.  An  excellent 
disinfectant  is  a  weak  solution  of  bromine  made  of 
five  fluid  ounces  of  the  British  Pharmacopoeia  solution 
diluted  with  fifteen  ounces  of  water.  One  objection  to 
its  use,  inseparable  however  from  its  virtues,  is  that  it 
has  a  pungent  odor.  A  weak  solution  of  carbolic  acid 
is  often  useful.  I  have  found  creasote  singularly 
efficacious,  and  in  a  ward  where  a  cancerous  patient 
is  so  often  a  source  of  annoyance  to  other  patients, 
the  nurses  have  assured  me  that  the  odor  of  creasote 
so  used  was  not  only  not  complained  of,  but  was 
even  liked.  Chlorozone  is  an  excellent  disinfectant. 
Alum  is  one  of  the  best  deodorants.  Its  property  of 
coagulating  albuminous  matter  makes  it  extremely 
useful  in  these  cases.  Chloride  of  zinc  has  also  its 
advantages;  but  the  lead  and  alum,  being  powerful 
astringents,  are  generally  to  be  preferred.  I  have 
tried  the  much-vaunted  chloralum  \vithout  discov- 
ering that  it  is  superior  to  the  agents  described  above. 
Dr.  Burow,  of  Konigsberg,  speaks  highly  of  the  effect 
of  the  chlorate  of  potash  upon  ulcerating  carcinoma. 
The  surface  is  sprinkled  once  a  day  with  the  salt. 

The  steady  use  of  styptics  and  disinfectants  is  often 
attended  by  good  effect  in  lessening  constitutional  infection 

47 


Intra-uterine  specu- 
lum. (Half-size.) 

By  remov- 


738  CANCER  OF  THE  UTEBUS. 

ing  the  foul  excretions  as  soon  as  formed,  and  by  altering  the  excreting 
surface,  absorption  of  noxious  material  is  prevented.  In  this  way  the 
agents  we  have  been  describing  exert  an  important  secondary  effect. 

The  Gonstitutional  treatment  or  management  of  cancer  patients  is  a 
matter  of  great  importance.  We  may  with  advantage  begin  by  elimi- 
nating the  Isedentia.  Foremost  amongst  these  is  excess  of  alcohol. 
Stimulants  carried  beyond  the  most  moderate  extent  are  decidedly 
injurious.  By  exciting  the  circulation,  they  increase  the  determination 
of  blood  to  the  diseased  organ,  and  promote  hemorrhage,  if  not  also 
the  advance  of  the  disease. 

The  diet  of  patients  suffering  from  cancer  is  a  matter  of  great 
moment.  Mr.  De  Morgan  called  attention  to  a  fact,  the  truth  of  which 
cannot  be  doubted,  namely,  that  the  disease  occurs  for  the  most  part 
in  persons  strong  and  well-nourished,  and  remarkable  for  general  good 
health.  This  shows  that  the  disease  does  not  arise  from  want  of  tone 
or  defect  of  nutrition.  Hence  it  would  appear  very  doubtful  whether 
it  is  wise  to  recommend  the  patient,  as  is  often  done,  "  to  keep  up 
well,"  to  take  plenty  of  nourishment,  to  use  stinuilants,  with  the  view 
of  counteracting  this  supposed  poisoned  state  of  system.  If  an  undue 
amount  of  nourishment  is  taken,  a  fair  share  of  it  will  go  to  the 
increase  of  the  disease,  and  stimulants  which  are  taken  to  the  extent  of 
quickening  the  circulation  will  at  the  same  time  increase  that  of  the 
tumor  and  accelerate  its  growth.  The  restriction  to  a  light  milk  and 
farinaceous  diet  has  been  recommended  from  early  times.  A  distin- 
guished physician  told  Mr.  De  Morgan  that  his  wife  had  cancer  of  the 
uterus ;  he  kept  her  for  a  long  time  on  the  sparest  vegetable  diet,  just 
enough  to  sustain  life ;  the  disease  disappeared.  Years  afterwards  the 
cancer  reappeared  and  destroyed  her,  circumstances  having  prevented 
her  from  observing  the  same  regime  as  before. 

Rest  is  commonly  necessary.  But  if  it  be  found  that  moderate 
exercise,  as  in  driving,  does  not  increase  pain  or  hemorrliage,  it  is  desi- 
rable to  take  it.  Physiological  rest  is  the  most  important.  The  wise 
physician  will  exercise  great  reserve  in  enforcing  sexual  abstinence  in 
the  great  majority  of  cases  of  uterine  disease.  But  in  the  case  of 
cancer,  his  injunction  should  be  decided.  The  direct  and  remote  evils 
produced  by  intercourse  are  so  great  that  regard  for  the  patient's  safety 
leaves  no  doubt  as  to  the  necessity  of  abstinence.  Attacks  of  hemor- 
rhage, even  fatal,  have  been  traced  to  imjjrudence  in  this  respect. 
That  the  activity  of  the  disease  is  promoted  by  it  there  can  be  no 
doubt.  And  in  the  not  improbable  event  of  pregnancy,  the  risk 
encountered  is  vital. 

The  internal  use  of  remedies  is  greatly  limited  to  the  fulfilment  of 
special  accidental  indications.  The  bowels  commonly  demand  atten- 
tion. Constipation  is  a  troublesome  complication.  It  must  be  met 
by  suitable  aperients,  and  by  enemata. 

Bromine  and  iodine  internally  were  greatly  relied  upon  by  Boinet. 
Iron  seems  indicated  by  the  degraded  state  of  the  blood.  But  it  is  not 
often  well  borne.  Salines  I  have  found  of  great  service.  Bismuth, 
strychnine,  hydi'ocyanic  acid  will  occasionally  be  required  to  allay 
irritability  of  stomach.  I  have  seen  in  many  cases  remarkable  benefit 
from  cod-liver  oil. 


DISEASES    OF    THE     VAGINA.  739 


CHAPTER  LI. 
THE  DISEASES  OF  THE  VAGINA. 

COLPITIS:  SIMPLE,  INFECTIOUS,  ACUTE,  CHRONIC;  DISPLACE- 
MENTS ;  WOUNDS ;  DILATATION;  ATROPHY;  SLOUGHING;  CIC- 
ATRICES; VESICO-VAGINAL  AND  RECTO-VAGINAL  FISTULA: 
RUPTURED  PERINEUM;  NEW  FORMATIONS:  FIBROUS  TU- 
MORS; SARCOMATA;  CYSTIC  TUMORS;  HEMATOMA;  CAL- 
CULI;  CANCER. 

Some  of  the  abnormal  conditions  of  the  vagina  have  been  described 
in  preceding  chapters  (see  Atresia,  Leucorrhoea,  &c.).  It  will  here  be 
necessary  to  describe  those  which  have  received  insufficient  attention. 

Vaginitis  or  Colpitis. 

Acute  vaginitis  sometimes  follows  labor,  the  result  apparently  of 
contusion  of  structures  in  a  state  of  exalted  vascularity.  In  these 
cases  exfoliation  or  desquamation  of  the  epithelial  layer  is  very 
active,  so  that  the  bared  surface  presents  a  raw,  velv^ety,  red,  angry 
appearance.  Even  during  pregnancy  the  intense  vascularity  of  the 
vagina  disposes  to  free  shedding  of  epithelium,  which  often  collects 
about  the  summit  of  the  vagina  in  the  form  of  a  creamy  pasma,  or  in 
shreds  or  pellicles. 

Acute  vaginitis  may  also  occur  from  exposure  to  cold  during  a  men- 
strual period,  from  injury,  from  the  introduction  of  foreign  substances, 
from  the  use  of  irritating  powders  or  injections.  In  children  it  may 
be  caused  by  ascarides,  by  neglect  of  cleanliness,  by  improper  manipu- 
lation. At  page  77  I  have  referred  to  the  association  of  vaginitis  with 
the  eruptive  fevers.  Scarlatina,  especially,  affects  the  genito-urinary 
mucous  tract,  and  thus  I  have  known  intense  vaginitis  produced.  The 
first  case  of  the  kind  I  saw  was  that  of  a  young  woman  in  Chomel's 
wards  at  the  Hotel  Dieu,  in  1840.  In  these  cases  there  is  prolific  gen- 
eration and  casting  off  of  epithelium,  attended  and  followed  by  a 
severe  form  of  leucorrhoea. 

Leucorrhoea  in  children  is  not  very  uncommon,  and  when  observed 
is  sometimes  the  source  of  most  distressing  suspicions.  It  is  therefore 
eminently  necessary  to  call  attention  to  the  fact  that  children  are  liable 
to  non-virulent  discharges,  depending  upon  accidental  causes.  The 
symptoms  of  vaginitis  and  vulvitis  in  children  are :  in  the  acute  stage, 
the  patient  complains  at  the  onset  of  itching  or  burning  at  the  vulva. 
This  is  increased  during  micturition.  A  whitish  opaque  moisture  is 
formed  over  the  surface  of  the  labia,  and  these  are  often  redder  than 
in  the  normal  state.     The  patient  has  often  a  difficulty  in  walking,  the 


740  DISEASES    OF    THE    VAGINA. 

friction  increasing  the  irritation  of  the  inflamed  surfaces.  In  the 
chronic  state,  the  discharge  is  a  serous  or  lactescent  moisture ;  there  is 
little  pain  in  the  vulva,  but  sometimes  a  dull  pain  above  the  pubes, 
spreading  to  the  groins  and  inner  part  of  the  thighs. 

This  form  of  vulvo-vaginitis  has  been  noticed  at  the  time  of  denti- 
tion, from  indigestion,  from  exposure  to  heat  and  fatigue — as  from 
dancing, — froui  constitutional  diathesis,  especially  the  strumous,  resem- 
bling in  this  respect  the  tumid  chronic  inflammation  of  the  conjunctiva 
and  nares. 

The  treatment  consists  in  putting  the  child  in  a  warm  bath  every 
two  or  three  days,  applying  demulcent  lotions,  as  poppyhead,  mallow, 
or  linseed  decoctions,  or  weak  acetate  of  lead,  and  in  regulating  the 
secretions  ;  in  the  use  of  iron,  iodine,  and  cod-liver  oil. 

The  most  common  cause  of  acute  or  subacute  colpitis  is  gonoi^rhoeal 
infection.  In  this  case  the  mucous  membrane,  especially  at  the  fundus 
of  the  vagina,  is  intensely  red.  There  is  copious  muco-purulent  secre- 
tion of  a  yellowish  or  greenish  tint,  sometimes  tinged  with  blood. 
This  is  found  chiefly  at  the  fundus  of  the  vagina,  surrounding  and 
bathing  the  vaginal-portion  of  the  uterus,  which  is  involved  in  the 
like  condition. 

An  experienced  practitioner  will  generally  recognize  the  specific 
character  of  this  inflammation  ;  but  it  is  easy  to  fall  into  error  in  diag- 
nosis. The  moral  and  social  complications  are  at  times  so  intricate,  and 
the  reasons  for  dissimulation  on  the  part  of  the  patients  are  so  strong 
and  various,  that  even  in  the  presence  of  the  most  convincing  clinical 
proof,  it  will  rarely  be  wise  to  commit  ourselves  to  a  plain  expression 
of  opinion.  The  subjects  themselves  may,  moreover,  be  perfectly  in- 
nocent and  unconscious  of  the  nature  of  the  affection.  And  we  must 
not  always  expect  to  be  dealt  with  candidly.  What  we  say  will  per- 
haps be  misinterpreted  or  misrepresented.  A  circumspect  reticence 
therefore  becomes  a  virtue  and  a  duty  in  the  physician. 

Gonorrhoeal  colpitis  is  very  apt  to  invade  the  cervical  canal,  and 
thence  to  pass  into  the  chronic  stage,  a  condition  analogous  to  gleet  in 
the  male. 

It  is  also  apt  to  spread  along  the  urethra.  This  is  more  frequent, 
says  Guerin,  than  is  commonly  thought.  Occasionally  the  orifice  of 
the  urethra  is  inflamed,  swollen,  dotted  with  red  points  or  pimples,  cor- 
responding to  the  openings  of  the  lacunse,  and  in  such  cases  recogni- 
tion of  urethritis  is  easy ;  but  when  the  disease  is  internal,  and 
when  no  mucus  or  pus  appears  externally,  detection  becomes  more 
difficult.  When  any  doubt  exists,  the  patient  should  be  prevented 
from  em]3tying  the  bladder  for  several  hours ;  the  finger  should  then 
be  introduced  into  the  vagina,  and  drawn  along  the  anterior  wall,  so 
as  to  press  out  any  purulent  matter  collected  within  the  urethra. 

Dr.  Giles,  Dr.  Noeggerath,  and  Dr.  Angus  Macdonald,  have  written 
interesting  clinical  memoirs  on  latent  gonorrhoea,  w'lih.  special  reference 
to  the  puerperal  state.  They  have  shown  that  at  this  time  there  is  a 
peculiar  danger  of  peritonitis  if  gonorrhoea  existed. 

Chronic  catarrhal  inflammation  commonly  occurs  after  rejieated  acute 
inflammations,  as  from  menstrual   suppression,  gonorrhoeal  infection, 


TEEATMENT.  741 

childbed,  in  chlorotic  or  scrofulous  persons,  from  uterine  catarrh,  the 
irritation  of  uterine  polypi,  or  hypertrophied  vaginal-portion,  disloca- 
tions of  the  uterus,  the  formation  of  morbid  growths,  and  ulcerative 
processes.  It  is  also  frequent,  and  often  at  first  acute  in  character,  in 
newly-married  women,  from  excess  or  awkwardness  in  intercourse. 

Vaginal  catarrh  is  of  importance  from  its  liability  to  spread  to  the 
uterus,  and  thence  to  the  tubes;  and  it  disposes  to  intussusception  and 
prolapsus  of  the  vagina. 

Inflammation  of  the  submucous  fibrous  coat  of  the  vagina  is  not 
common  apart  from  traumatic  causes.  Iviwisch  has  called  attention  to 
the  occurrence  of  abscesses  in  this  tissue  during  pregnancy. 

But  there  is  a  chronic  form,  not  very  uncommon,  the  result  in  most 
of  the  cases  which  I  have  seen  of  imperfect  or  irritating  intercourse. 
It  is  marked  by  thickening  of  the  walls  of  the  vagina,  the  formation 
of  abscesses,  and  a  degree,  sometimes  considerable,  of  atresia  of  the 
canal. 

Diphtheritic  inflammation  most  frequently  occurs  in  childbed,  and 
especially  in  lying-in  hospitals  ;  but  I  have  seen  an  example  in  home 
practice.  There  is  a  form  of  vaginitis  in  which  the  mucous  membrane 
is  covered  by  pellicles,  or  flakes,  white,  very  brittle,  to  which  the  name 
diphtheritis  is  sometimes  given.  At  best  this  should  be  called  pseudo- 
diphtheritis.  It  is  not  usually  attended  by  febrile  symptoms.  The 
vaginitis  is  not  very  acute,  it  is  strictly  limited  to  the  nmcous  mem- 
brane,, and  the  pellicle  consists  almost  entirely  of  agglomerated  epithe- 
lium scales.  The  formation  of  the  pellicle  seems  simply  due  to  the 
preponderance  of  these  scales  over  the  mucous  plasma.  If  the  mucous 
plasma  were  more  abundant,  the  discharge  would  be  called  leucorrhoea. 

The  Symptoms  and  Diagnosis  of  Colpitis. 

In  the  acute  stage  there  is  pain,  often  severe,  characterized  as  "  burn- 
ing," in  the  part^  Dyspareunia  is  almost  necessarily  present.  Some 
febrile  excitement  attends.  Unlike  metritis,  it  is  very  rarely  complica- 
ted with  peritonitis.  Hence  the  local  and  constitutional  symptoms  are 
less  severe.  Dysuria  may  also  attend  the  gonorrhoeal  form.  In  this 
form  also  there  is  leucorrhoea  of  the  character  described.  But  absolute 
diagnosis  can  only  be  made  out  by  aid  of  the  speculum,  when  we  can 
take  note  of  the  vivid  red  mucous  membrane,  and  see  the  discharge  in 
situ. 

In  the  chronic  and  non-specific  forms,  pain  is  not  so  much  com- 
plained of.  I  must  refer  to  the  chapter  on  "  Leucorrhoea  "  for  further 
information  on  this  subject.  When  the  disease  has  involved  the  cervi- 
cal canal,  vaginal  injections  are  inefficient.  Topical  applications  inside 
the  cervix  are  essential.  One  form  of  pain,  "  Vaginismus,"  has  been 
described  in  the  chapter  on  "  Dyspareunia." 

The  treatment  of  colpitis  consists  greatly  in  observing  rest  and  cleanli- 
ness. To  aid  in  securing  rest,  an  essential  condition  often  is  to  keep  the 
inflamed  walls  of  the  vagina  apart.  This  is  accomplished  by  wearing 
Sims's  or  my  vaginal-rest  for  hours  during  the  day ;  by  using  a  plug  of 
cotton- wool  steeped  in  tannin  and  glycerin,  changing  it  two  or  three 


742  DISEASES    OF    THE    VAGINA. 

times  a  day,  or  by  simple  rest  in  the  recumbent  posture.  Douches  of 
tepid  water  or  poppy-head  decoction  are  often  of  signal  service.  In 
the  more  acute  stages  injections  of  lead  in  proportion  of  one  drachm  to  a 
pint  of  water  are  best  borne;  later,  sulphate  of  zinc,  chloride  of  zinc, 
alum,  tannin  are  more  serviceable.  The  gonorrhoeal  inflammations  may 
be  treated  exactly  on  the  same  principles  as  the  similar  affection  in  the 
male.  The  quickest  method  of  cure  is  undoubtedly  to  touch  the  dis- 
eased surface  lightly  every  other  day  with  solid  nitrate  of  silver,  or  to 
swab  it  with,  a  strong  solution.  This,  of  course,  requires  skilled  aid 
and  the  speculum. 

Displacements  of  the  Vagina. — Displacements  of  the  vagina  can 
hardly  arise  without  the  preliminary  condition  of  relaxation,  or  of 
displacement  of  the  uterus.  Whether  prolapsus  of  the  uterus  be  the 
cause  or  the  effect  of  prolapsus  of  the  vagina  is  a  question  already  dis- 
cussed. No  doubt,  prolapsus  of  the  vagina  is  commonly  associated 
with  prolapsus  of  the  uterus,  but  I  believe  prolapse  of  the  vagina  may 
exist  independently.  There  is  a  preparation  in  St.  George's  Museum 
(No.  xiv,  106)  which  seems  to  show  that  vaginal  rectocele  may  exist 
without  prolapse  of  the  uterus. 

Hernias  consist  in  an  inversion  of  the  anterior  wall  of  the  vagina 
with  the  bladder, — cystooele  vaginalis  ;  or  in  inversion  of  the  posterior 
wall  from  the  lower  end  of  the  rectum, — rectocele  vaginalis;  or  in  a  hernia 
vaginalis  posterior, — enter ocele  vaginalis.  This  last  form  consists  in 
dilatation  of  Douglas's  pouch  to  a  hernial  sac,  so  that  the  peritoneum 
is  carried  deeply  down  behind  the  wall  of  the  vagina  to  the  perineum. 
The  intestinal  folds  contained  in  it  drag  upon  the  vagina,  then  tilt  it 
from  behind,  pressing  from  above  downwards  more  and  more  of  its 
circumference,  according  to  the  degree  to  which  the  uterus  follows  the 
traction  and  descends.  The  prolapsus  of  the  vagina  thus  produced 
gradually  proceeds  to  a  complete  inversion,  which  contains  in  its  cavity 
the  prolapsed  uterus,  which  in  consequence  of  this  traction  undergoes 
very  frequently  a  considerable  or  even  monstrous  elongation  of  its 
cervix.  Commonly  the  rectum  is  also  protruded  to  a  prolapsus  by  the 
hernia.  In  rare  cases,  in  consequence  of  the  mass  of  intestinal  convo- 
lutions accumulating  in  the  hernial  sac  between  the  uterus  and  the 
inverted  vagina,  laceration  of  the  posterior  wall  of  the  vagina  has 
occurred  with  a  fatal  issue. 

The  treatment  of  vaginal  prolapse  and  hernia  in  most  cases  merges 
in  that  which  is  indicated  for  prolapsus  of  the  uterus.  In  some  lew 
cases  a  Hodge  or  stem-pessary  may  be  useful.  Astringent  injections 
are  almost  always  serviceable.  But  when  the  prolapse  is  great  so  that 
folds  of  vagina  protrude  through  the  vulva,  becoming  liable  to  chafing  , 
and  inflammation,  surgical  treatment  is  necessary  to  remove  the  redun- 
dant portion.  A  piece  of  the  mucous  membrane  of  size  and  form  indi- 
cated by  the  conditions  of  the  case  must  be  dissected  off,  and  the  edges 
brought  together,  so  as  to  contract  the  canal.  It  will  commonly  be 
necessary  to  combine  this  proceeding  with  the  perineal  operation. 

The  vagina  is  liable  to  wounds  from  the  introduction  of  foreign 
bodies,  from  accidents,  and  from  surgical  operations. 

The  most  frequent  cause  of  the  lesions  that  come  before  the  surgeon 


WOUNDS.  743 

is  severe  labor.  The  vagina  is  liable  to  undergo  laceration,  contusions, 
leading  to  partial  necrosis,  or  sloughs.  Hence  result  cicatrices,  M'hich 
may  lead  to  occlusion  of  the  vagina,  or  fistulous  opening  into  the 
bladder  or  rectum.  Yesico-vagmal  fistula  may  be  produced  by  the 
mere  pressure  of  the  head,  long  continued,  jamming  tlie  bladder  against 
the  pubes. 

In  precipitate  labor,  or  in  protracted  labor  in  primiparse  where  the 
vulva  is  rigid,  the  perineum  is  apt  to  undergo  laceration,  backwards 
to  the  anus. 

The  anterior  commissure  also,  as  I  pointed  out  many  years  ago  (see 
Tyler-Smith's  "Obstetric  Medicine,")  is  liable  to  rupture,  wdience 
severe  hemorrhage  may  arise. 

There  is  a  singular  preparation  in  the  Museum  of  St.  George's 
Hospital  (Series  xiv,  108).  It  is  a  case  of  laceration  of  the  vagina 
from  coition.  There  is  a  rent  passing  along  the  upper  two  inches  of 
the  vagina,  dividing  the  mucous  membrane  and  the  adjoining  fibres  of 
the  muscular  coat.  The  rent  deepens  as  it  ascends,  and  on  a  level  with 
the  OS  uteri  has  broken  through  into  the  peritoneal  cavity.  The  hole 
in  the  peritoneum  is  not  quite  large  enough  to  admit  the  little  finger. 
The  subject  was  an  old  woman. 

The  most  trivial  tvounds  of  the  vagina  are  sometimes  followed  by 
profuse  bleeding.  This  is  especially  the  case  during  pregnancy.  But 
at  any  time  the  slightest  nick,  puncture,  or  incision  may  give  rise  to 
profuse  bleeding  if  the  patient  assume  the  erect  posture  and  be  exposed 
to  any  exertion.  A  surgeon  snipped  off'  a  very  small  warty  excrescence 
from  the  vagina  just  inside  the  vulva.  The  woman  nearly  bled  to 
death.  Plugging  and  the  application  of  styptics  failed  to  arrest  it.  I 
passed  a  curved  needle  armed  with  a  suture  so  as  to  get  quite  under 
the  little  wound.  Tlie  suture  drawn  tight  effectually  controlled  the 
bleeding.  This  is  the  surest  plan  to  adopt.  A  short  sewing  needle 
held  in  a  forceps  might  on  emergency  answer.  But  in  some  cases, 
steady  pressure  with  a  pad  of  lint  steeped  in  per(rhloride  of  iron  or 
other  styptic  may  be  enough,  absolute  rest  in  recumbent  posture  being 
understood. 

Professor  E.  Martin  describes  a  condition  of  the  vagina  which  is 
observed  under  particular  circumstances.  It  consists  in  a  temporary 
dilatation  of  the  fundus,  not  the  result  of  stretching  or  distension,  but 
which  is  caused  by  a  pathological  action  of  the  neighboring  ligaments ; 
that  is,  the  pubo-vesico-uterine,  and  the  sacro-uterine,  the  muscular 
bundles  of  which  contract.  The  examining  finger  finds  the  roof  of  the 
vagina  so  wide  that  it  seems  as  if  its  walls  were  applied  close  to  the 
sides  of  the  pelvis.  This  condition  is  found  when  there  is  hemorrhage 
with  uterine  colic,  and  in  secondary  puerperal  hemorrhage  (and  especially 
in  abortion,  R.  B.).  In  such  cases  the  os  uteri  is  open,  and  the  roof  of 
the  vagina  seems  higher  than  usual.  Under  the  use  of  means  to  arrest 
the  bleeding  this  dilatation  disappears  completely  in  twenty-four  hours. 
Dr.  V.  Haselberg,  speaking  on  the  subject,  says  the  dilatation  takes 
place  under  the  effort  of  the  uterus  to  empty  itself.  (Monats.  fur 
Geb.,  1869.) 

There  is  a  form  of  atrophic  contraction  of  the  vagina  which  takes 


744  DISEASES    OF    THE    VAGINA. 

place  in  advancing  age.  •  The  walls  lose  elasticity,  the  canal  becomes 
smaller,  sometimes  funnel-shaped  or  conical,  the  apex  being  at  the  roof, 
where  the  remains  of  the  atrophied  cervix  uteri  may  be  felt.  Some 
cases  of  this  kind  are  not  easy  to  distinguish  from  the  strictures  which 
ensue  occasionally  upon  cancer.  This  atrophic  contraction  is  most 
common  in  women  who  have  abandoned  the  habit  of  sexual  intercourse. 
It  explains  the  rupture  in  the  specimen  in  St.  George's  Museum,  de- 
scribed at  page  743. 

The  vagina  may  be  the  seat  of  various  uleerative  processes. 

Excoriations  occur  from  catarrhal  suppuration  or  the  chafing  of  fibroid 
polypus,  of  pessaries,  &c. 

Syphilitic  sores  may  occur  in  any  portion  of  the  vaginal  canal,  but 
the  most  frequent  locality  is  the  fold  or  duplicature  at  the  fundus,  into 
which  the  vaginal  portion  of  the  cervix  uteri  is  inserted.  This  is  com- 
monly attended  by  colpitis.  To  the  touch  an  excavated  syphilitic  sore 
may  at  first  impose  upon  the  surgeon  for  the  os  uteri. 

The  tuberculous  and  cancerous  ulcerations  generally  begin  on  the 
vaginal-portion,  and  spread  to  the  roof  of  the  vagina.  The  latter 
especially  are  unhappily  frequent,  and  often  lead  to  destruction  of  the 
walls  between  bladder  and  rectum,  establishing  cloaca. 

The  vagina  is  also  sometimes  ulcerated  from  without,  through  the 
burrowing  of  subperitoneal  abscesses  which  make  their  way  into  the 
vagina. 

Sloughing  of  the  vagina  also  occurs  as  the  result  of  the  bruising  and 
pressure  encountered  during  protracted  labor,  from  diphtheritis,  from 
necrosis  in  severe  fevers,  from  peri-vaginal  hjematoceles  and  abscesses, 
from  necrosis  resulting  from  the  pressure  of  fibroid  tumors  so  large  as 
to  become  impacted,  or  from  the  impaction  of  a  retroverted  gravid 
uterus. 

The  healing  of  vaginal  sloughs  by  granulation  frequently  results  in 
the  formation  of  cicatrices.  Those  cicatrices  which  lead  to  atresia  or 
stenosis  of  the  canal  have  been  described,  in  their  pathological  and 
therapeutical  bearing,  under  " Dysmenorrhoea  from  retention."  But 
cicatrices,  in  the  form  of  bands  or  falciform  projections  into  the  vagina, 
not  extensive  enough  to  close  the  canal,  are  not  uncommon.  They 
produce  distress  of  a  different  kind.  The  cicatrix  I  have  most  frequently 
met  with  is  a  crescentic  or  falciform  band,  beginning  at  the  os  uteri  by 
one  horn  and  the  vaginal  wall  by  the  other,  at  a  distance  of  an  inch 
or  more.  This,  contracting,  may  half  shut  off  the  os  uteri  from  the 
canal  of  the  vagina  below,  forming  a  pouch  or  sac  above.  It  also  not 
uncommonly  pulls  the  cervix  uteri  to  one  side,  or  forwards  or  back- 
wards, producing  deviation  of- the  uterus.  It  thus  becomes  a  cause  of 
dysmenorrhoea,  sometimes  of  monorrhagia,  and  of  dyspareunia. 

I  have  seen  these  cicatrices  follow  labor,  instrumental  and  not  in- 
strumental, also  cauterization  of  the  os  uteri  by  potassa  cum  calce,  and 
even  by  nitrate  of  silver  incautiously  applied.  They  have  also  followed 
'the  use  of  too  concentrated  chromic  acid  and  perchloride  of  iron. 

The  symptoms  caused  by  these  cicatrices  are  so  severe  that  treat- 
ment to  relieve  them  assumes  importance.  This  treatment  consists  in 
dividing  the  cicatrices  so  as  to  allow  the  vaginal  wall  to  resume  its 


FISTULA.  745 

natural  form.  When  the  cicatrix  extends  up  the  vaginal-portion  this 
part  should  be  set  free,  by  dividing  the  horn  which  seizes  and  binds  it 
to  the  vaginal  wall.  The  first  step  is  to  dissect  off  the  adventitious 
membrane  from  the  vaginal-portion,  so  as  to  restore  this  part  to  its 
normal  condition;  and  then  several  nicks  should  be  made  at  different 
points  of  the  crescentic  edge,  as  deeply  as  is  felt  to  be  safe,  taking  great 
care  of  course  not  to  go  through  the  vaginal  wall.  This  operation  is  best 
done  without  the  speculum.  The  cicatrix  is  made  tense  by  the  fore- 
finger of  the  left  hand,  and  then  the  edge  of  a  Simpson's  metrotome  is 
turned  upon  it.  When  thus  nicked  these  cicatrices  have  a  tendency  to 
disappear.  But  it  is  likely  that  the  incisions  will  have  to  be  repeated 
from  time  to  time  before  they  are  overcome.  Sometimes  the  bleeding 
attending  this  operation  is  very  profuse;  and  it  is,  I  think,  always 
prudent  to  plug  the  vagina  firmly  with  j)ledgets  of  lint  soaked  in  olive 
oil  and  carbolic  acid.  The  operation  should  in  every  case,  however 
slight  it  may  seem  to  be,  be  performed  on  the  patient  in  bed.  Absolute 
rest  in  the  recumbent  posture  should  be,  rigidly  enforced  for  four  or 
five  days  afterwards.  If  these  precautions  are  adopted  there  will  prob- 
abl}^  be  no  bleeding  of  importance;  if  neglected,  profuse,  even  fatal 
hemorrhage  may  result.  Under  no  consideration  should  the  operation 
be  performed  in  the  out-patient's  room  of  a  hospital,  or  in  the  physi- 
cian's consulting-room. 

A  day  or  two  after  the  operation  it  is  desirable  to  apply  a  Hodge 
pessary,  so  shaped  that  it  will  keep  the  roof  of  the  vagina  on  the 
stretch,  so  as  to  obviate  the  disposition  to  contract,  which  the  scar  fre- 
quently manifests.  I  have  seen  extensive  cicatrices  gradually  disap- 
pear under  the  continual  stretching  of  a  Hodge  pessary.  In  one  case, 
that  of  a  lady  who  had  suffered  extensive  sloughing  after  labor,  the 
vagina  was  very  contracted.  But  in  a  year  the  canal  was  so  nearly 
restored  to  its  natural  state  that  she  subsequently  bore  a  child  at  term 
without  artificial  aid.  Fig.  167  represents  a  not  uncommon  form  of 
utero-vaginal  cicatricial  band.  Raised  on  the  finger  it  is  made  tense 
for  division. 

There  are  four  kinds  of  fistulce  of  the  genital  organs, — 1.  Between 
the  bladder  or  urethra  and  vagina;  the  most  common.  2.  Between 
bladder  and  uterus;  rare.  3.  Between  rectum  and  vagina;  not  very 
rare.  4.  Between  rectum  and  uterus ;  very  rare.  To  these  might  be 
added  uterine  fistulae,  communicating  with  an  abscess  in  the  pelvis; 
and  fistulse  opening  into  the  vagina  from  perimetric  abscesses  or  retro- 
uterine hsematocele. 

The  most  common  seat  of  the  vesico-vagina[  fistula  is  near  or  half  an 
inch  below  the  anterior  edge  of  the  os  uteri'.  This  is  the  part  which  is 
most  liable  to  compression  between  the  child's  head  and  the  os  pubis 
during;  labor.  It  is  not  so  often  the  result  of  laceration  as  of  mortifica- 
tion  from  protracted  pressure.  I  have  no  doubt  that  in  many  cases  the 
mortification  has  been  due  to  the  pressure  of  an  edge  of  the  short  straight 
forceps,  the  instrument  having  been  applied  according  to  the  old  and 
erroneous  law,  one  blade  behind  the  pubes.  In  these  cases  the  urine 
may  either  be  retained  for  a  few  days  after  labor,  or  it  may  flow  by  the 
urethra  with  more  or  less  pain.     But  at  the  end  of  a  week  or  so  the  pa- 


746 


DISEASES     OF    THE    VAGHSTA. 


tient  becomes  conscious  that  her  water  runs  awaj  by  the  vagina  more 
or  less  continuously;  in  fact,  that  she  cannot  hold  it;  that  she  is,  as  the 
expression  goes,  "always  wet."  Excoriation  of  the  external  genitals 
is  a  frequent  consequence.  Sometimes,  in  the  recumbent  posture,  the 
vulvar  sphincter  being  unimpaired,  the  vagina  forms  a  pouch,  which 


Fig.  167. 


Cicatricial  band  binding  os  uteri  to  roof  of  vagina. 


will  retain  a  considerable  quantity  of  urine,  acting  the  part  of  a  sub- 
sidiary bladder.  But  on  rising  or  exertion  this  accumulation  is  dis- 
charged, and  the  dribbling  goes  on.  The  incontinence  begins  from 
the  falling  of  the  slough.  This  leaves  a  hole  in  the  septum  between 
bladder  and  vagina,  the  edges  of  which  gradually  cicatrize.  In  this 
process  the  hole  contracts,  often  so  much  that  there  may  be  great 
difficulty  in  finding  it.  But  a  hole  that  will  barely  admit  a  fine 
probe  is  big  enough  to  drain  off  the  urine  as  fast  as  it  is  secreted.  The 
hole  may  be  big  enough  to  admit  the  tip  of  the  finger.  The  greater 
part  of  the  urethra  may  be  destroyed.  In  some  cases  the  lower  seg- 
ment of  the  uterus  is  lost,  as  well  as  the  base  of  the  bladder.  The  an- 
terior lip  of  the  OS  uteri  is  not  unconuiionly  lost.  In  one  case  lately 
under  my  care  no  cervix  could  be  found.  There  was  nothing  in  the 
roof  of  the  vagina  to  be  found  but  a  fistulous  opening  admitting  the 
tip  of  the  finger.  This  was  cured  in  two  operations;  and  tlie  patient 
menstruated  through  the  bladder. 

The  diagnosis  is  established  by  sight  and  by  touch.  Whenever 
incontinence  of  urine  has  come  on  after  labor,  examination  by  finger 
and  sound,  and  by  speculum  is  indicated.  The  patient  lying  on  her 
left  side,  the  catheter  or  sound  is  passed  into  the  bladder,  and  the  fore- 
finger in  the  vagina  carried  to  the  os  uteri,  and  then  brought  down 
along  the  course  of  the  urethra,  feeling  for  the  sound  through  the 
fistula,  if  one  exists.  Generally  the  puckered  cicatrix  of  the  fistula  is 
felt,  and  guides  to  the  opening.     Through  this  opening  is  felt  project- 


^  FISTULA.  747 

ing  a  velvety  nipple-like  mass,  the  mucous  membrane  of  the  bladder. 
Through  this  the  point  of  the  sound  is  sometimes  carried  from  the 
bladder.  This  evidence,  complete  in  itself,  may  be  extended  by  the 
use  of  Sims's  speculum.  The  perineum  being  lifted  away  the  aperture 
may  usually  be  seen ;  the  mucous  membrane  of  the  bladder  bulging 
like  a  cherry  or  a  raspberry,  and  urine  oozing  or  dribbling  through  it. 
The  point  of  the  sound  may  be  seen  in  the  fundus  of  the  vagina. 

In  the  case  of  recto-vaginal  fistula,  the  opening  may  have  become 
so  contracted  that  escape  of  faces  into  the  vagina  is  only  occasional, 
that  is,  when  the  stools  happen  to  be  liquid.  It  may  require  some 
pains  to  detect  the  opening.  It  usually  lies  rather  low  down,  at  the 
point  where  the  floor  of  the  ])erineum  begins  to  incline  forward  from 
the  hollow  of  the  sacrum.  It  may  be  made  evident  by  finger  and 
sound. 

Operations  for  Vesioo-vaginal  and  Recto-vaginal  Fistulce. — Experi- 
ence is  now  so  ample  that  a  decided  conclusion  can  be  arrived  at  as  to 
the  best  method  of  proceeding.  The  complicated  methods  in  which 
shot,  splints,  lead-plates,  and  other  mechanical  contrivances,  constituted 
such  an  essential  part,  are  now  either  discarded,  or  ought  to  be  so.  All 
have  given  way  to  a  very  simple  proceeding.  The  instruments  really 
useful  are  very  few,  1.  A  Sims's  speculum.  2.  A  good  forceps  to 
hold  the  edge  of  the  fistula  whilst  paring ;  some  surgeons  use  a  hook. 
I  have  contrived  a  forceps  which  answers  admirably  for  this  purpose. 
It  has  the  gi'eat  advantage  of  seizing  accurately  a  long  strip  of  mem- 
brane without  tearing  through.  3.  Right  and  left-handed  fistula- 
knives  set  at  an  angle  of  45°,  and  a  straight  one.  4.  Small  stout 
needles,  straight  for  about  an  inch  from  the  edge,  and  then  gently 
curved  at  the  point.  5,  A  forceps  with  leaded  bite  and  a  sliding  catch 
to  hold  the  needles  at  any  required  angle,  6.  Fine  silver  or  iron  wire, 
Chinese  silk  or  catgut. 

The  tubular  needles  through  which  wire  is  propelled  by  a  cog-wheel, 
are  really  clumsy  contrivances.  They  are  very  apt  to  disappoint  at  the 
critical  moment,  and  are  not  so  easy  to  manipulate  accurately  as  the 
simple  needles  described.  If  wire  be  preferred,  the  ingenious  tubular 
wire  clamps  of  Dr.  Aveling  for  closing  the  wound  answer  best.  The 
two  ends  of  each  suture  are  passed  through  a  tube,  this  is  then  run 
down  to  the  wound  by  the  fingers,  bringing  the  edges  accurately 
together,  and  the  tube  is  then  secured  by  a  perforated  shot.  The 
advantages  of  this  contrivance  are :  accurate  closure  of  the  wound  by 
avoiding  twisting ;  and  great  facility  in  removing  the  sutures,  it  being 
simply  necessary  to  cut  the  tube  across,  when  an  end  of  suture  is  always 
found,  and  easily  withdrawn  by  forceps.  I  have  used  this  several  times 
with  success.  But  the  simple  silk  suture  answers  equally  well.  It  was 
long  thought  that  the  recent  success  attained  was  due  to  the  use  of  silver 
or  iron  sutures.  Gosset  led  the  way  by  curing  a  case  with  silver-gilt 
wire  in  1834.  Sims  and  others  adopted  metal  wire.  But  the  expe- 
rience of  Charles  Brooke  has  been  strangely  overlooked  in  the  history 
of  this  operation.  This  surgeon  thirty  years  ago  cured  fistulse  by  silk 
sutures  secured  by  his  beads.  He  was  also,  as  I  can  testify  from  per- 
sonal observation,  eminently  successful  in  curing  perineal  lacerations 


748  VESICO-VAGINAL    FISTULA. 

by  silk  and  bead  sutures.  The  simplicity  and  success  now  attained 
may  be  attributed  mainly  to  the  introduction  of  ansesthesia,  which 
enables  the  operator  to  proceed  with  deliberation  and  accuracy,  and  to 
the  use  of  Sims's  duck-bill  speculum,  which  gives  such  complete  access 
to  the  part.  An  objection  to  Sims's  speculum,  however,  is  the  necessity 
for  its  being  held  by  an  assistant,  and  its  liability  to  slip  at  a  critical 
moment.  This  is  greatly  lessened  by  using  Weiss's  speculum,  which 
can  be  fixed  to  the  patient  by  a  fenestrated  blade  applied  outside  to 
the  back. 

Before  operating  it  is  necessary  to  be  assured  that  the  parts  are  in  a 
healthy  condition.  Any  morbid  condition  of  the  cervix  uteri  should 
be  healed.  Any  constitutional  taint  should  be  removed.  The  time 
selected  should  be  a  week  after  a  menstrual  period,  and  not,  as  a  rule, 
until  three  months  after  recovery  from  labor.  No  operation  should  be 
done  during  gestation.  The  bowels  should  be  relieved  by  castor  oil 
and  enema.  The  position  of  the  patient  may  be  the  semi-prone  or  the 
lithotomy  position.  If  the  latter  be  preferred,  the  hands  are  fastened 
to  the  ankles  by  Prichard's  wristbands  and  anklets.  Assistants  on 
either  side  support  the  legs,  and  by  retractors  or  fingers  help  to  keep 
the  vulva  open  ;  another  holds  back  the  perineum  by  a  Sims's  speculum. 
The  operator  seizes  the  margin  of  the  fistula  by  a  suitable  toothed  for- 
ceps or  hook,  and  pares  off  a  circular  strip  of  the  mucous  membrane  of 
the  vagina,  including  the  cicatricial  tissue  of  the  edge,  but  carefully 
avoiding  the  mucous  membrane  of  the  bladder.  The  edges  should  be 
bevelled  o&,  making  the  pared  surface  oblique,  so  that  whilst  the  vaginal 
mucous  membrane  is  cut  away  for  about  half  an  inch  all  round  the 
fistulous  opening,  the  opening  in  the  bladder  itself  is  not  enlarged. 
The  bleeding  is  not  often  great.  A  little  time  may  be  given  to  stop  it 
by  syringing  with  ice-cold  water  and  pressure  with  sponges.  The 
sutures  are  then  to  be  passed,  the  needle  entering  and  coming  out  a 
good  half-inch  beyond  the  fresh  pared  edge.  They  should  take  in  the 
entire  thickness  of  the  pared  edge,  but  avoid  the  mucous  membrane  of 
the  bladder.  They  should  be  about  four  or  five  to  the  inch.  They 
should  not  be  drawn  tight  until  all  are  passed.  When  tied  it  is  useful 
to  test  the  accuracy  of  the  closure  by  trying  the  interspaces  of  the 
sutures  by  a  fine  bent  probe.  If  this  passes  in,  another  suture  may 
be  useful  at  the  part.  Superficial  sutures  between  the  deep  ones  are 
commonly  useful.  A  winged  catheter  should  then  be  inserted  in  the 
bladder. 

Such  is  the  simple  operation  which  is  the  outcome  of  all  the  inge- 
nious and  complicated  proceedings  initiated  by  Charles  Brooke,  and 
carried  out  bv  Brown,  Sims,  Bozeman,  and  numerous  other  surgeons. 

The  after-treatment  consists  mainly  in  rest.  The  catheter  should 
be  taken  out  and  cleansed  daily,  care  being  taken  that  the  reintroduc- 
tion  is  done  gently.  The  sutures  may  be  removed  on  the  sixth  or 
seventh  day. 

When  the  cervix  uteri  is  involved  in  the  loss  of  substance  it  becomes 
a  question  whether  the  opening  can  be  closed  without  also  closing  the 
OS  uteri.  Sometimes  it  is  necessary  to  pare  tlie  posterior  surface  of  the 
OS  uteri,  making  this  one  side  of  the  wound  which  is  to  be  united  to 


LACERATION  OF  THE  PERINEUM.  749 

the  neck  of  the  bladder.  In  many  cases  the  anterior  lip  of  the  os 
uteri  may  be  pared  and  made  to  form  one  side  of  the  wound.  This, 
united  with  the  neck  of  the  bladder,  leaves  the  os  uteri  open  behind  it. 

When  the  fistula  is  vesico-uterine,  it  may  be  impossible  to  ^et  at  the 
fistula  itself.  In  such  a  case  Jobert  closed  the  os  uteri.  The  urine 
was  then  retained.  J.  E,.  Lane,  having  operated  in  this  manner,  found 
that  the  uterus  enlarged  afterwards.  This  was  at  first  thought  to  be 
due  to  retention  of  menstrual  fluid,  and  a  puncture  was  made  through 
the  place  of  union.  This  resulted  in  an  abortion  of  four  months'  gesta- 
tion. It  is  conjectured  that  the  semen  got  access  along  the  track  of 
one  of  the  sutures.     The  patient  was  cured  by  repeating  the  operation. 

In  those  still  more  severe  cases  in  which  the  urethra,  neck,  and  floor 
of  the  bladder  have  been  destroyed,  various  attempts  more  or  less  suc- 
cessful have  been  made.  Jobert  proposed  to  make  an  opening  into  the 
rectum,  and  then  to  close  the  vulva  completely.  Baker  Brown  pro- 
posed to  make  a  new  urethra  by  passing  a  small  trocar  through  the 
tissues  under  the  pubic  arch,  keeping  a  catheter  in  until  a  permanent 
canal  is  formed,  and  then  making  a  new  floor  for  the  bladder  by  draw- 
ing the  uterus  down  and  uniting  the  sides  of  the  vagina  together.  Dr. 
Kidd  describes  a  case  in  which  a  large  opening  existed  from  the  vagina 
into  the  bladder,  through  which  the  fundus  of  the  bladder  protruded. 
There  not  being  sufficient  tissue  for  Brown's  operation,  he  resolved  to 
close  the  vagina  entirely,  leaving  a  small  opening  anteriorly  for  the 
urethra.  This  he  did  by  paring  off'  the  mucous  membrane  from  the 
inner  surfaces  of  the  labia  and  posterior  wall  of  the  vagina,  dissecting 
as  high  up  as  he  could  in  this  part,  to  avoid  making  a  pouch,  and 
having  removed  the  nymphse  anteriorly  he  placed  a  No.  10  catheter 
close  up  under  the  pubic  arch,  and  thus  brought  the  pared  surfaces  into 
contact  by  four  deep-quilled  sutures,  as  in  the  operation  for  ruptured 
perineum.  A  spring  pad,  like  a  truss  invented  by  Trelat,  of  Paris, 
was  fitted  on  to  the  orifice  of  the  urethra,  and  the  woman  was  able  to 
retain  the  urine  perfectly. 

In  some  cases  of  incontinence  of  urine  the  urethral  pad  referred  to 
is  extremely  useful.  Dr.  Thomas  Chambers  showed  me  a  case  in 
which  great  relief  was  gained  by  a  similar  contrivance.  It  acts  as  a 
substitute  for  the  natural  sphincter.  The  transverse  obliteration  of  the 
vagina  described  by  Simon  may  be  the  last  resource. 

At  one  time  small  fistulse  were  treated  by  the  actual  cautery,  in  the 
hope  that  the  resulting  slough  would  be  followed  by  cicatricial  con- 
traction and  closure.  This  method  cannot  be  depended  upon.  The 
more  certain  and  scientific  procedure  by  suture  ought  to  be  adopted  at 
once. 

Vesico- vaginal  fistulse  once  fairly  healed  are  not  very  liable  to  re- 
lapse. But  Dr.  Bourdon  (Arch,  Gen.  de  Med,,  1872)  reports  four 
cases  of  relapse  from  Yerneuil's  cUnique,  all  in  women  who  became 
pregnant. 

Lacerations  of  the  -perineum  may  be  of  various  degrees.  It  is  prac- 
tically enough  to  consider  two.  These  are  distinguished  by  the  reten- 
tion of  the  integrity  of  the  sphincter  ani  in  the  one  case,  and  by  its  being 
torn  through  in  the  other. 


750  LACERATION    OF    THE    PERINEUM. 

The  loss  of  the  perineal  floor  is  attended  by  other  inconveniences 
besides  the  increased  liability  to  prolapsus.  Indeed,  prolapsus  uteri 
does  not  always  follow  on  laceration  of  the  perineum.  I  have  known 
sterility  persist  until  the  perineum  was  restored.  Probably  the  loss  of 
the  retentive  capacity  of  the  vagina  was  the  cause.  The  subject  feels 
"  open."     She  is  conscious  of  being  unsound. 

When  laceration  of  the  perineum  is  detected  at  the  time  of  its  occur- 
rence, it  is  best  to  stitch  it  up  at  once.  Three  or  four  sutures  of  wire 
or  carbolized  silk  are  applied  by  means  of  a  needle  set  in  a  handle,  or 
even  by  long  needles  held  by  forceps.  This  is  now  a  recognized  prac- 
tice approved  by  experience.  Immediate  union  usually  takes  place. 
Union  is  also  sometimes  effected  by  keeping  the  parts  in  contact  by 
means  of  "  serrefines."  Indeed,  even  without  sutures,  more  or  less 
perfect  restoration  will  not  unfrequeutly  be  effected.  Granulations 
extend  from  the  fork  of  the  fissure  forwards,  filling  up  the  space.  This 
process  is  much  promoted  by  keeping  a  strip  of  lint  soaked  in  solution 
of  chloride  of  soda  in  the  wound.  If  the  opportunity  of  applying 
sutures  within  twelve  hours  of  the  occurrence  of  the  injury  be  lost,  it 
is  better  to  wait  for  perfect  cicatrization,  and  the  recovery  of  the  pa- 
tient from  the  puerperal  state.  About  three  months  after  labor  is 
generally  early  enough. 

The  operation  for  restoring  the  split  perineum  is  well  described  by 
Mr.  James  Lane  (Cooper's  Surgical  Diet.,  1872).  The  operation,  when 
the  sphincter  ani  is  not  injured,  is  as  follows :  A  portion  of  skin  and 
mucous  membrane  is  dissected  off  on  each  side  of  the  lower  half  of  the 
vulva,  so  as  to  form  a  raw  surface,  which  should  be  about  an  inch  and 
a  half  in  length  on  each  side,  the  right  and  left  portions  being  continu- 
ous with  each  other  below  across  the  median  line.  It  should  be  an  inch 
or  more  in  depth  antero-posteriorly  at  the  loM'er  part  next  the  anus, 
but  may  diminish  to  about  half  an  inch  in  depth  towards  its  upper 
part.  It  is  better  first  to  mark  the  outline  of  the  raw  surface  by  inci- 
sions with  the  scalpel,  and  then  to  dissect  off  the  mucous  membrane, 
the  thinnest  possible  layer  of  which  should  be  removed.  Care  should 
be  taken  that  the  denuded  surface  is  not  situated  too  far  outwards  upon 
the  buttock,  or  too  far  inwards  towards  the  vagina,  but  just  where  the 
opposite  sides  would  naturally  and  readily  come  in  contact.  The  deep 
sutures  which  are  to  hold  the  quills  are  next  to  be  inserted.  For  this 
purpose  the  most  convenient  instrument  is  a  strong  needle  set  in  a 
handle,  with  an  eye  near  the  point,  and  bent  at  a  right  angle  at  about 
three  and  a  half  inches  from  the  point,  the  part  from  the  angle  to  the 
point  being  slightly  curved.  This  should  be  entered  through  the  skin 
on  the  left  side  of  the  patient,  about  an  inch  external  to  the  cut  sur- 
face, and  be  brought  out  close  to  the  posterior  edge  of  that  surface, 
taking  hold  of  as  much  tissue  as  possible,  and  should  be  then  thrust 
onwards  through  the  opposite  side  at  a  corresponding  depth.  The  eye 
near  the  point  may  then  be  threaded  with  a  strong  wire  suture,  and 
the  needle  is  withdrawn,  carrying  the  suture  with  it.  Mr.  Lane  uses 
four  deep  sutures  of  silver  wire,  and  fastens  them  to  perforated  ivory 
bars,  which  represent  the  quills.  Each  ivory  l)ar  is  perforated  with 
four  holes,  about  half  an  inch  apart.     One  of  these  should  be  ready 


OPERATION.  751 

threaded  with  two  pieces  of  wire,  each  piece  being  looped  througli  the 
two  adjacent  holes,  and  when  these  four  sutures  have  been  passed,  they 
are  threaded  through  the  holes  in  the  second  ivory  bar,  and,  being 
drawn  tight,  the  whole  is  firmly  secured  by  twisting  the  ends  together, 
first  of  the  two  lower,  and  then  of  the  two  upper  wires.  By  having 
the  wires  looped  on  the  one  side,  no  fastening  is  required  on  that  side, 
while  on  the  other  side  two  adjacent  wires  are  fastened  simultaneously, 
thus  saving  time,  and  securing  a  more  uniform  pressure  on  the  part. 
The  quill  suture  serves  to  hold  the  deep  part  of  the  cut  surfaces  in 
contact,  but  the  cutaneous  edges  must  also  be  held  together  by  four  or 
five  superficial  sutures  of  finer  wire  or  catgut. 

The  bowels  should  be  restrained  by  opium  for  seven  or  eight  days. 
A  winged  catheter  should  be  kept  in  the  bladder,  or  the  urine  should 
be  drawn  off  every  eight  hours.  The  deep  sutures  should  be  cut  and 
removed,  together  with  the  ivory  clamps,  at  the  end  of  forty-eight  hours. 
Some  oedematous  swelling  generally  takes  place,  but  soon  subsides  when 
the  pressure  of  the  quill  suture  is  removed.  If  left  longer  than  this, 
irritation  and  suppuration  are  apt  to  be  set  up,  and  no  compensating  ad- 
vantage is  obtained.  The  superficial  sutures  need  not  be  removed  till 
the  sixth  or  seventh  day.  The  bowels  may  now  be  opened  by  a  brisk 
ajjerient,  followed  by  an  enema. 

In  the  cases  where  the  perineum  has  been  torn  through  into  the 
anus,  somewhat  greater  care  is  necessary  to  secure  accurate  contact,  and 
especially  to  prevent  any  aperture  being  left  between  the  rectum  and 
newly  made  perineum.  The  latter  untoward  result  may  be  best 
avoided  by  splitting  the  recto-vaginal  septum  for  a  short  distance  in 
the  horizontal  direction,  at  the  point  where  it  forms  a  sort  of  eperon 
at  the  centre  of  the  torn  part.  Then,  by  turning  up  the  vaginal 
portion  of  the  split  septum,  and  causing  the  two  lowest  of  the  deep 
sutures  to  take  a  hold  of  it  on  its  new  surface  as  they  are  passed 
through,  it  will  eflPectually  cover  the  spot  where  otherwise  recto-vaginal 
communication  might  probably  be  left,  while  it  will  at  the  same  time 
increase  the  thickness  of  the  lower  part  of  the  new  perineum.  In 
this  class  of  cases  division  of  the  sphincter  is  beneficial,  as  the  action 
of  the  muscle  otherwise  tends  to  separate  the  surfaces,  and  especially 
to  open  the  torn  angle  of  the  wonab.  But  an  incision  on  one  side  only 
is  sufficient. 

In  the  still  more  severe  cases  in  which  the  recto-vaginal  septum  is 
torn  for  a  greater  or  less  extent  upwards,  the  operation  above  described 
will  be  insufficient,  as  a  recto-vaginal  communication  would  be  almost 
certain  to  remain.  It  is  therefore  necessary  first  to  unite  the  recto- 
vaginal septum,  and  afterwards  to  restore  the  perineum.  To  unite 
the  recto-vaginal  septum  the  edges  must  be  pared  on  each  side,  and  a 
sufficient  number  of  wire  sutures  inserted.  These  may  be  secured  by 
simply  twisting  their  ends,  no  quill  suture  being  required.  When 
union  is  complete  and  firm,  which  will  usually  be  at  the  end  of  about 
three  weeks,  the  second  operation  for  the  restoration  of  the  perineum 
above  described  may  be  undertaken. 

To  secure  fine  adaptation  of  the  rectal  and  vaginal  mucous  and  of 
the  cutaneous  structures,  the  operation  as  described  by  M.  Hulke  is 


752  DISEASES    OF    THE    VAGINA. 

effective  :  Two  triangular  flaps  of  vaginal  mucous  membrane  are  first 
dissected  up  ;  then  the  cleft  in  the  rectum  is  sewn  with  three  fine  silk 
sutures,  the  ends  of  which  are  left  in  the  bowel.  Several  sutures  of 
the  same  material  are  then  adapted  to  the  vaginal  mucous  membrane 
that  had  been  previously  dissected  up.  Next,  the  raw  surfaces  made 
by  thus  raising  the  flaps  of  mucous  membrane  are  brought  together 
with  quilled  sutures  passed  deeply,  making  a  long  and  thick  perineum  ; 
and  lastly,  the  tegumentary  edges  of  this  are  joined  with  fine  silk 
sutures. 

The  new  formations  in  the  vagina  are  not  numerous  or  frequent. 
They  consist  almost  exclusively  in  fibrous  tumors,  cystic  tumors,  sar- 
comata, or  the  papillary  excrescence,  and  cancer. 

Fibrous  tumors  and  sarcomata  are  developed  in  the  fibrous  or  mus- 
cular coat  of  the  vagina,  and  often  but  not  invariably  are  associated 
with  similar  formations  in  the  uterus.  The  fibroid  tumors  project  into 
the  vagina,  and  sometimes  assume  a  considerable  bulk.  Tumors  also 
form  in  the  connective  tissue,  between  the  rectum  and  vagina,  and  are 
developed  equally  towards  either  canal,  or  bulge  out  more  into  one  or 
the  other. 

The  sarcomata  proceed  mostly  from  the  uterus,  and  from  the  cervix. 
Mr.  Curling  (Pathol.  Trans.,  vol.  i)  describes  a  firm  solid  tumor 
growing  from  the  upper  part  of  the  vagina,  to  which  it  was  attached 
by  a  broad  peduncle,  which  commenced  just  behind  the  meatus  of  the 
urethra.  The  tumor  consisted  of  a  mass  of  dense  fibrous  tissue  partly 
arranged  in  large  lobules,  and  developed  in  the  submucous  areolar 
tissue  of  the  vagina.  It  had  been  forming  for  many  years,  and  lately 
had  projected  outside  the  vulva.  Free  bleeding  occurred  from  one  or 
two  large  vessels  at  the  posterior  part  of  the  peduncle. 

Papillary  outgrowths  are  not  so  common  in  the  vagina  as  on  the 
cervix  uteri,  but  they  sometimes  assume  a  cauliflower-shape,  with  a 
more  or  less  defined  stalk.  At  the  entrance  of  the  vagina  they  take 
the  form  of  condylomata. 

Cystic  tumors  are  occasionally  found  in  the  walls  of  the  vagina. 
Their  most  common  seat  in  my  experience  is  the  anterior  wall,  along 
the  course  of  the  urethra.  They  are  certainly  of  rare  occurrence. 
Thus  Scanzoni  says  (1856)  that  lie  had  only  met  with  one  case,  and 
West's  experience  furnishes  only  two.  Several  clear  examples  have 
come  under  my  observation.  McClintock  gives  the  histories  of  two 
cases.  The  origin  and  nature  of  these  cysts  are  not  clearly  determined. 
In  some  cases  possibly  they  resemble  fibro-cystic  tumors  of  the  uterus, 
the  cystic  element  being  specially  developed.  In  others,  according  to 
Huguier,  they  originate  in  obstructed  nuicous  follicles.  Scanzoni  says, 
in  autopsies,  one  meets  with  cysts,  the  size  of  a  pea  or  of  a  cherry  ;  but 
accurate  information  always  proves  that  these  neoplasms  were  not  de- 
veloped in  the  walls  of  the  organ,  but  in  the  peri-vaginal  cellular 
tissue.  Rokitansky  also  says  the  primitive  seat  of  these  cysts  is  out- 
side the  vagina,  with  which  they  have  only  a  secondary  relation.  This, 
I  think,  I  have  verified  in  some  cases.  Strictly  vaginal  cysts  must  be 
distinguished  from  vulvar  cysts,  which  are  not  uncommon.  There  are 
two  specimens  of  cysts  removed  from  the  vagina  in  Guy's  Museum, 


CANCER.  753 

Nos.  2281^°  and  2281*^  I  have  removed  two  by  wire-ecraseur.  In 
one  case  it  appeared  to  me  that  the  origin  of  the  cyst  was  a  blood- 
tumor  or  hsematoma.  I  have  seen  several  hsematomas  of  the  walls  of 
the  vagina  not  always  traceable  to  labor.  The  absorption  of  the  blood 
would  leave  a  cyst  which  would  subsequently  be  filled  with  serum  or 
muco-purulent  fluid. 

The  treatment  consists  in  removing  the  tumors  altogether,  if  this 
can  be  done  without  involving  too  extensive  a  wound.  Otherwise 
they  may  be  laid  freely  open  by  bistoury,  and  the  cavity  plugged  with 
tincture  of  iodine  on  lint. 

They  sometimes  burst  and  continue  to  pour  forth  an  offensive  dis- 
charge. There  was  recently  under  my  care  in  St.  Thomas's  a  case  of 
a  cyst  which  burst  into  the  urethra.  It  gave  rise  to  extreme  dysuria. 
It  caused  a  considerable  fluctuating  swelling  in  the  vagina.  It  was 
cured  by  free  cauterization  with  nitrate  of  silver  of  the  cavity  of  the 
cyst  through  the  urethra. 

Dr.  Gibb  described  (Path.,  Trans,  vol.  v)  a  specimen  in  which  small 
calculi  (phebolites)  were  taken  from  between  the  coats  of  the  vagina  in 
a  colored  woman. 

Primary  cancer  of  the  vagina  is  exceedingly  rare.  McClintock  says 
no  well-marked  and  undoubted  instance  has  fallen  under  his  notice. 
In  all  cases  of  vaginal  cancer,  the  disease  he  found  had  spread  from 
the  uterus  or  the  vulva.  Dr.  West  believes  that  the  rarity  of  primitive 
vaginal  cancer  has  been  exaggerated.  I  cannot  absolutely  contest 
McClintock's  statement,  but  I  have  now  and  then  met  with  a  peculiar 
contraction  of  the  vagina  in  old  women,  attended  with  ulceration  and 
offensive  discharges,  which  I  believed  to  be  of  cancerous  nature,  and  in 
which  I  concluded  that  the  uterus  was  not  involved. 

In  one  case  which  came  under  my  care  at  the  London  Hospital,  that 
of  a  woman  aged  seventy,  there  had  been  for  ten  months  a  sanguineous 
discharge  of  "dirty  white"  color,  pain  down  inside  thighs  and  lower 
belly,  chiefly  at  stool.  She  was  obliged  to  lie  down ;  she  felt  as  if 
sitting  on  a  sharp  instrument.  About  one  inch  up  the  vagina,  an 
annular  constriction  is  felt  just  admitting  the  finger;  through  this  is  a 
pouch,  at  the  back  of  which  is  the  enlarged  and  hardened  os  and  cervix 
uteri.  The  sensation  is  much  as  if  the  finger  passed  through  a  fistula 
into  the  rectum.  But  passing  one  finger  into  the  rectum  and  one  into 
the  vagina,  the  septum  is  felt  perfect,  and  her  "  stools  pass  the  right 
way."  Blood  flowed  on  examination.  Atresia  of  the  canal  is  not 
uncommon  when  the  vagina  is  the  seat  of  cancer.  Rare  as  is  vaginal 
cancer,  there  may  occasionally  be  seen  here  and  there  scattered  over 
the  vaginal  surface  independent  roundish,  or  flat  medullary  watery 
projections,  discoid  or  honeycomb  elevations  of  the  cauliflower  excres- 
cence. 

The  vagina  affords,  like  the  peritoneum,  clear  opportunities  of  ob- 
serving how  cancer  can  propagate  itself  by  contact.  Thus  it  is  not  un- 
common to  find  a  patch  of  cancerous  growth  on  the  opposing  surface  of 
the  primary  seat  of  the  disease.  Dr.  Cay  ley  describes  (Path.  Trans., 
xvii),  a  case  of  epithelioma  propagated  by  contact  from  the  posterior  to 
the  anterior  wall  of  the  vagina. 

48 


754  DISEASES    OF    THE    VULVA. 

The  diagnosis,  presuming  that  a  digital  examination  is  made,  is 
easy.  The  rough,  hardened,  contracted  walls  of  the  vagina  communi- 
cate a  sensation  different  from  that  of  the  healthy,  or  of  any  other  dis- 
eased state  of  the  vagina.  The  examination,  howsoever  gently  made, 
is  moreover  pretty  sure  to  cause  a  little  bleeding ;  and  the  offensive 
discharge  supplies  further  evidence. 

The  course  and  terminations  of  vaginal  cancer  resemble  those  of 
uterine  cancer.  Indeed,  in  almost  every  case  vaginal  cancer  is  but  an 
ulterior  stage  of  uterine  cancer.  The  disease  extending  deeper  invades 
the  rectum  and  bladder,  leading  probably  to  perforation.  Death  occurs 
through  exhaustion,  blood-infection,  and  degradation,  mechanical  im- 
pediment to  the  functions  of  the  bladder,  kidneys,  and  intestines. 

In  treatment  unhappily  little  can  be  done.  There  is  no  room  for 
attempt  at  ablation.  We  can  but  seek  to  arrest  progress  by  powerful 
caustics,  and  failing  this,  fall  back  on  palliative  measures.  Dr.  West 
in  one  case  found  great  benefit  from  the  free  use  of  acid  nitrate  of 
mercury.  Three  or  four  applications  produced  complete  cicatrization 
of  all  but  just  that  part  of  the  disease  which  affected  the  roof  of  the 
vagina.  There  the  application  was  extremely  difficult,  and  there  the 
disease  spread. 

The  palliative  treatment  differs  in  no  respect  from  that  described  as 
applicable  to  cancer  of  the  uterus. 


CHAPTER  LII. 

THE  DISEASES  OF  THE  VULVA. 

INFLAMMATION:  GENERAL  OR  PARTIAL;  OF  THE  VULVO-VAGI- 
NAL  GLANDS  ;  ABSCESSES  ;  ULCERATIONS;  SLOUGHS;  HEM- 
ATOMA; VARICOSITY;  PRURITUS;  HYPERTROPHY  OF  LABIA 
AND  CLITORIS;  "  ENDERMOPTOSIS ;"  NEUROMATA;  CYSTS; 
SYPHILITIC  WARTY  EXCRESCENCES;  LUPUS;  CANCER;  ME- 
LANOSIS; VASCULAR  EXCRESCENCE  OF  THE  MEATUS  URINA- 
RIUS;  FISSURE  OF  THE  VULVA.     COCCYGODYNIA. 

Some  of  the  diseases  of  the  vulva  are  marked  by  exquisite  pain. 
The  free  distribution  of  sentient  nerves,  the  riclmess  and  complexity 
of  the  vascular  apparatus,  and  the  multiplicity  of  the  delicate  organs 
accumulated  in  this  region  account  for  this  feature.  Another  condition 
to  be  noted  is  the  active  reflex  association  with  the  nervous  centres, 
cerebral  and  spinal.     This  is  remarkably  manifested  when  we  induce 


INFLAMMATION,  755 

anaesthesia  to  facilitate  examination  or  operations.  The  vnlva  seems 
ahnost  the  last  part  in  which  the  reflex  irritability  is  suspended.  The 
reactions  upon  the  general  nervous  system  are  often  complicated  and 
distressing,  and  are  not  seldom  overlooked.  In  addition  to  these  con- 
ditions, which  always  exist,  there  is  often  found  a  morbid  neurotic 
element  inherited  or  acquired,  or  a  blood  dyscrasia  or  diathesis,  as  gout. 

Inflammation  of  the  vulva. — vulvitis — may  be  partial,  that  is,  limited 
to  a  part  of  the  structures  of  the  vulva,  as  to  one  vulvo-vaginal  gland 
and  one  labium;  or  it  may  be  general,  that  is,  involving  all  the  struc- 
tures of  the  vulva  on  both  sides.  It  may  be  limited  to  the  vulva^ 
which  is  not  uncommon,  or  it  may  be  complicated  with  colpitis. 

The  vulva  is  liable  to  various  forms  of  inflammation  :  Erythema, 
phlegmonous  inflammation  of  the  labia,  acute  or  chronic,  furuncle,  ery- 
sipelas, herpes,  eczema,  prurigo,  and  the  follicular  inflammation  of 
Huguier.  QEdema  is  a  frequent  complication  of  these  affections.  They 
often  leave  a  degree  of  thickening,  hypertrophy,  or  sclerosis  of  the 
tissue  of  the  nymphse,  clitoris,  or  vulva. 

Inflammation  of  Bartholini's  glands  is  frequently  caused  by  unclean 
sexual  intercourse,  especially  of  a  gonorrhoeal  character,  I  have  seen 
a  chronic  inflammation,  which  had  lasted  ten  months,  disappear  quickly 
under  no  other  treatment  than  iodide  of  potassium.  I  had  suspected 
syphilitic  disease.  It  may  be  the  result  also  of  want  of  cleanliness, 
and  the  irritation  produced  by  the  retention  and  partial  drying  of  leu- 
corrhoeal  discharges. 

Inflammation  having  attacked  the  substance  of  the  gland,  causes 
extreme  pain  from  the  distension  of  the  gland  within  its  capsule  and 
the  surrounding  connective  tissue.  The  inflammation  may  be  limited 
to  the  gland  and  its  duct,  or  may  spread  to  the  loose  connective  tissue 
around.  In  either  case  abscess  may  form.  When  the  gland  is  the 
chief  seat  of  the  inflammation,  a  swelling  forms  of  an  ovoid  shape, 
distending  one  labium  major,  and  causing  it  to  protrude  so  as  to  overlap 
and  conceal  the  labium  on  the  other  side.  The  surface  of  the  tumor 
is  usually  vivid  red,  shining  from  tension,  and  bathed  with  a  serous 
mucus.  The  size  varies  from  that  of  a  pigeon's  egg  to  that  of  a  hen's 
egg.  Bulging  over  towards  the  opposite  side,  it  narrows  the  entrance 
of  the  vulva  so  that  the  introduction  of  the  finger  causes  exquisite 
pain.  It  is  generally  possible  to  detect  the  orifice  of  the  duct  of  the 
gland  on  the  inner  surface  of  the  labium.  Pus  accumulating  in  the 
gland  may  from  time  to  time  force  its  way  out  of  the  duct,  then  collect 
again.  But  most  often  this  mode  of  evacuation  is  imperfect,  and  great 
distension  is  the  result.  Even  when  the  abscess  has  burst,  an  obsti^ 
nate  secretion  of  pus  may  go  on  for  an  indefinite  time.  The  subjective 
sym])toms  are  intense  pain  and  a  sense  of  throbbing  in  the  part. 

When  the  inflammation  spreads  to,  or  has  its  chief  seat  in  the  cellular 
tissue  of  the  labium,  the  symptoms  and  appearances  are  similar.  Per- 
haps the  pain  is  less ;  but  pain  is  a  relative  term,  often  more  expressive 
of  individual  susceptibility  than  of  the  intensity  of  the  disease,  so  that 
no  conclusion  can  be  drawn  from  this.  Where  the  cellular  tissue  is 
aflected,  the  swelling  extends  much  beyond  the  limits  of  the  gland.    It 


756  DISEASES    OF    THE    VULVA. 

may  terminate  in   resolution,  but  suppuration  is,  I  think,  the  more 
common  event.     In  this  case  fluctuation  soon  becomes  evident. 

Abscess  of  the  gland  itself  will  not  often  burst.  After  a  time  the 
inflammation  may  even  subside,  and  the  cyst  formed  may  be  tolerated. 
I  have  known  many  examples  of  this  condition.  It  is  nevertheless 
desirable  to  lay  them  open  when  detected,  as  they  may  at  any  time  be 
the  occasion  of  renewed  trouble. 

In  the  treatment  of  inflammation  of  the  labia  majora  and  Bartho- 
lini's  gland,  the  first  thing  to  enjoin  is  rest.  Indeed,  this  injunction  is 
not  very  likely  to  be  disregarded,  the  pain  on  movement,  especially  in 
the  upright  posture,  is  too  agonizing  for  that.  If  suppuration  has  not 
begun,  leeches,  poultices,  and  lead  lotion  give  most  relief,  and  dispose 
to  resolution.  When  the  formation  of  pus  is  made  out,  a  tolerably  free 
incision  should  be  made.  As  the  part  is  very  vascular  free  bleeding  may 
follow ;  but  this  gives  such  obvious  relief  that  it  ought  not  to  be  imme- 
diately stopped.  If  it  goes  beyond  desirable  bounds  it  can  be  readily 
stopped  by  compresses  alone,  or  by  a  tent  soaked  in  perchloride  of  iron. 
A  poultice  should  be  applied  after  the  incision.  An  abscess  of  the  cel- 
lular tissue  thus  treated  will  commonly  heal  without  further  trouble. 
But  if  it  is  the  result  of  inflammation  of  the  gland  itself,  something 
more  may  be  necessary.  The  contents  of  the  inflamed  Bartholini's 
gland  are  not  always  simple  pus ;  a  glairy  tenacious  mucus  often  is 
mixed  with  pus.  The  distension  may  have  produced  a  cystic  dilata- 
tion of  the  gland,  the  inner  surface  of  which  will  secrete  even  after  it 
is  laid  open,  unless  its  character  be  changed  by  the  free  application  of 
some  strong  escharotic  or  irritant.  I  have  never  found  any  trouble 
Avith  these  cysts,  if  their  cavity  be  stuffed  with  a  strip  of  lint  soaked 
in  tincture  of  iodine.  They  quickly  shrivel  up ;  the  remaining  cavity 
gets  filled  by  granulations. 

If  abscesses  of  the  vulva  are  allowed  to  burst,  or  have  been  insuffi- 
ciently laid  open,  fistulous  tracts  are  apt  to  form,  which  keep  up  great 
irritation  and  discharge,  and  even  inflammation  and  induration  of  the 
tissues  around.  The  treatment  of  these  sinuses  consists  in  giving  them 
a  free  external  opening,  and  in  injecting  a  solution  of  iodine  into  their 
track. 

Ulcerative  loss  of  substance  occurs  in  the  form  of  excoriations, 
superficial  ulcers,  and  small  follicular  and  larger  abscesses.  The  vulva 
is  also  liable  to  lupus  and  syphilitic  sores. 

Sloughs  of  the  vulva  are  especially  apt  to  follow  severe  labor.  They 
may  occur  after  typhoid,  scarlatina,  diphtheria,  and  may  be  primary,  as 
in  the  noma  of  young  children.  Sloughs  following  labor  may  result 
in  various  degrees  of  cicatricial  atresia. 

Hemorrhages  of  the  Vulva. 

Hsematoma,  or  thrombus  of  the  labia  majora,  is  produced  under  the 
obstruction  caused  to  the  return  of  blood  by  the  advancing  head 
during  labor,  and  also  by  the  bruising  and  laceration  occasioned  by  the 
passage  of  the  head.  It  may  also  proceed  from  submucous  rupture  of 
varicose  veins.     It  sometimes  attains  the  size  of  a  fist,  or  even  of  a 


HEMORRHAGES.  757 

child's  head,  and  consists  sometimes  more  in  a  diffused  extravasation 
of  blood  in  the  connective  tissue  of  the  labia,  sometimes  rather  in  a 
collection  of  blood  poured  out  into  a  sac  formed  by  rending  away  of 
the  mucous  membrane  from  the  underlying  tissues.  If  the  mucous 
membrane  be  torn  through,  free  external  bleeding  may  ensue.  The 
extravasation  may  spread  up\vai"ds,  dissecting  the  mucous  membrane 
up,  and  burrowing  behind  it  far  into  the  pelvis.  Suppuration  at  times 
takes  place  in  the  sac,  and  gives  rise  to  repeated  bleedings.  I  have 
seen  a  marked  case  of  hsematoraa  of  the  clitoris  and  urethra. 

The  pudenda  are  subject  to  a  varicose  dilatation  of  the  vessels,  a  con- 
dition which  may  prove  serious.  During  pregnancy  the  vaginal  and 
pudendal  plexuses  become  still  more  highly  developed  ;  the  augmented 
afflux  of  blood,  and  the  occasionally  increased  obstacle  to  its  return 
from  the  pelvis,  may  lead  to  considerable  dilatation  of  these  plexuses. 
The  inside  of  the  vulva  and  lower  part  of  vagina  at  times  assume  a 
distinctly  convoluted  appearance,  owing  to  the  prominence  of  the 
vessels  ;  these  bulge  forth  turgid,  elastic,  deep  red,  or  purple. 

In  this  condition  should  a  breach  of  surface  take  place  at  any  point, 
profuse,  even  fatal  bleeding  may  easily  occur.  A  blow  may  rupture 
the  vessels  by  bruising  them  against  the  pubic  bones.  Simpson  says, 
"  In  the  Scotch  law  courts  during  the  last  five-and-twenty  years  a  con- 
siderable number  of  trials  have  taken  place  in  consequence  of  women 
bleeding  to  death  after  sustaining  some  injury  of  the  pudenda.  In  most 
of  these  cases  all  that  was  alleged  as  the  cause  of  death  was  that  the 
woman  had  received  a  kick  on  the  part  at  the  time  she  was  pregnant, 
and  that  a  slight  laceration  had  been  produced,  from  which  the  fatal 
hemorrhage  took  place."  Some  years  ago  a  butcher  was  tried  at  Bris- 
tol for  killing  a  married  woman.  Rupture  of  the  pudendal  vessels 
had  taken  place  during  coitus.  But  rupture  of  the  gorged  vessels  may 
occur  spontaneously,  that  is,  without  any  direct  violence  to  the  part. 

Varicose  veins  of  the  legs  during  pregnancy  may  present  a  similar 
state  of  turgidity,  entailing  a  like  danger.  I  have  known  a  woman 
bleed  to  death  from  a  slight  injury  inflicted  on  a  bunch  of  such  veins. 

The  varicose  condition,  of  which  the  foundation  was  laid  in  preg- 
nancy, persists  more  or  less  when  the  pregnancy  is  ended.  The  affected 
vessels  become  less  turgid,  but  may  undergo  changes  disposing  to  dan- 
ger in  another  way.  Thrombosis  taking  place  in  them,  necrosis  of  the 
walls  of  the  vessels  may  ensue,  and  thus  becoming  perforated,  may 
be  the  source  of  hemorrhage  or  ulcers ;  inflammation  of  a  low,  some- 
times erysipelatous  type  is  common. 

When  hemorrhage  takes  place  from  varicose  vessels  of  the  vulva  or 
vagina,  the  one  effectual  remedy  is  pressure.  This  must  be  flrmly  ap- 
plied. The  best  way  is  by  plugging  the  vagina  above  and  down  to 
the  level  of  the  bleeding  points.  The  horizontal  posture  and  moderate 
diet  of  course  will  be  enforced.  Simple  compresses  dipped  in  cold 
water  will  answer  the  purpose.  But  occasionally  it  may  be  found  de- 
sirable to  soak  them  in  a  solution  of  perchloride  of  iron. 

Although  pregnancy  is  the  usual  antecedent  of  varicose  veins,  I  have 
known  very  severe  cases  which  could  not  be  traced  to  this  condition. 

Pruritus  is  one  of  the  most  distressing  of  the  affections  of  the  vulva. 


758  DISEASES    OF    THE    VULVA. 

It  is  associated  with,  or  dependent  upon,  a  variety  of  conditions,  so 
that  it  may  generally  be  regarded  as  symptomatic.  Before  determin- 
ing upon  a  course  of  treatment,  it  is  a  clear  indication  to  investigate 
thoroughly  the  state  of  the  pelvic  organs,  and  even  to  study  the  gen- 
eral condition  of  the  system.  In  some  cases  the  irritation  depends 
upon  diabetes.  In  some  there  is  a  gouty  diathesis  or  lithiasis,  the 
blood  carrying  irritating  elements  to  every  organ  and  tissue  of  the 
body  ;  pain  is  especially  evoked  in  certain  elected  parts,  the  vulva 
being  one  of  these.  In  some  there  is  congestion  or  inflammation  of 
the  cervix  uteri,  and  the  attendant  discharges  appear  to  be  the  imme- 
diate cause  of  the  valvar  pruritus;  but,  in  some  instances,  there  is 
pruritus,  intra-vaginal,  as  well  as  pudendal,  without  any  discharge. 
Then,  in  a  considerable  number  of  cases,  there  is  obvious  pudendal 
disease,  as  herpes,  eczema,  erythema,  scabies,  pediculi. 

In  some  apparently  inflammatory  cases,  it  is  difficult  to  say  whether 
inflammation  or  neurosis  predominates.  In  many  of  the  most  painful 
of  these  disorders  there  is  no  very  obvious  inflammation,  and  in  others, 
where  inflammation  is  obvious  enough,  the  pain,  although  generally 
troublesome,  is  more  endurable.  Some  of  them  have  been  described 
under  the  head  of  climacteric  diseases.  It  is  at  this  period  that  the 
most  troublesome  cases  occur.  This,  indeed,  is  especially  the  epoch  of 
irregular  disorderly  nervous  affections.  But  other  forms  may  occur  in 
young  women,  married  or  single.  One  form  especially  arises  during 
pregnancy,  a  time  when  the  nervous  system  is  in  a  state  of  peculiar 
erethism,  and  when  the  seat  of  the  pruritus  is  peculiarly  vascular  and 
hyper^sthetic.  I  have  seen  a  very  troublesome  form  in  single  young 
w^omen  following  a  sedentary  occupation  as  governesses.  The  sitting 
may  have  an  injurious  local  eflect,  but  probably  emotional  and  'other 
centric  nervous  conditions  may  be  influential.  And  this  may,  I  think, 
be  stated  as  a  general  proposition  :  there  must  be  exaggerated  centric 
irritability  as  well  as  an  eccentric  irritation  to  produce  the  marked 
forms  of  pruritus.  Indeed,  it  is  not  uncommon  to  find  in  obstinate 
cases  that  a  general  irritation  or  hypersesthesia  of  the  whole  skin  be- 
comes gradually  developed. 

It  is  remarkable  that  most  of  these  painful  affections  of  the  vulva 
are  aggravated  at  the  menstrual  epochs.  This  is  due,  no  doubt,  to  the 
exalted  centric  irritability  attending  ovulation,  as  well  as  to  the  increased 
local  vascular  fluxion.  A  similar  exacerbation  is  observed  in  neuralgia 
of  the  face  and  other  parts.  Indeed,  there  are  cases  of  intense  vulvar 
pruritus  where  no  local  lesion  can  be  detected,  which  might  with  pro- 
priety be  called  vulvar  neuralgia. 

A  considerable  proportion  of  cases  are  due  to  inflammation  of  the 
structures  about  the  vulva.  These  are  already  described.  A  not  un- 
common form  in  climacteric  women  tending  to  obesity  is  eczema.  In 
cases  of  this  kind  the  disease  is  not  limited  to  the  vulva  but  extends  to 
the  dependent  fold  of  the  abdomen,  to  the  folds  of  the  groins,  to  the 
upper  parts  of  the  thighs;  in  fact,  to  all  tliose  skin-surfaces  which 
overlap  each  other  and  chafe.  The  skin  loses  its  natural  epidermal 
character,  becomes  moist,  red,  angry-looking,  approaching  to  the  appear- 
ance of  inflamed  mucous  membrane.    Sometimes  aphthous  or  diphther- 


TEEATMENT.  759 

itic  patches  form.  The  labia  majora  are  often  much  swolFen,  even 
hypertrophied.  Minute  vesicles  or  pustules  give  place  to  scabs.  Some- 
times little  abscesses  form  and  burst. 

I  have  seen  pruritus  from  eczema  brought  on  by  gonorrhoea,  and  the 
use  of  irritating  lotions.  In  one  such  case,  that  of  a  young  woman,  a 
pustular  eczema  spread  all  over  the  mous  Veneris,  the  labia,  and  inner 
side  of  the  thighs.  Nitrate  of  silver  had  been  used  freely  without 
benefit.  She  was  cured  by  healing  the  attendant  metritis  and  vaginitis, 
and  by  the  local  application  of  zinc  ointment. 

Pruritus  is  not  uncommon  in  connection  with  cancer  of  the  uterus 
or  vagina.  My  observation  confirms  the  statement  of  McClintock  that, 
in  many  cases,  pruritus  of  the  vulva  is  one  of  the  earliest  symptoms  of 
cancer  of  the  womb. 

In  some  cases  the  pruritus  is  due  to  the  breeding  of  pediculi.  These 
are  effectually  treated  by  mild  mercurial  ointments.  In  hospital,  the 
nurses  ask  for  stavesacre  for  this  purpose.  It  answers  well.  But 
there  are  other  cases  in  which  the  affection  is  in  no  way  associated  with 
parasites,  Mdiich  are  remarkably  benefited  by  stavesacre.  The  prurigo 
senilis,  for  example,  is  successfully  treated  by  Mr.  Balmanno  Squire's 
formula,  consisting  of  oil  of  the  seeds  1,  lard  7.  In  this  disease  I  have 
also  seen  great  advantage  from  the  application  of  a  pasma  formed  of 
flowers  of  sulphur  and  water. 

A  not  uncommon  form  of  vulvitis  is  the  vulvar  folliculitis  of  Huguier. 
This  affects  the  labia  majora,  the  external  aspect  of  the  labia  minora, 
the  genito-crural  folds,  and  is  limited  to  the  sebaceous  glands  and  hair- 
bulbs  of  these  parts.  These  parts  appear  slightly  swollen,  rosy,  and 
are  the  seat  of  small  elevations  due  to  inflammation  of  the  sebaceous 
glands  and  hair-bulbs.  These  are  very  numerous,  are  at  first  small, 
then  enlarge,  and  resemble  pustules,  and  soon  suppurate.  Bursting, 
they  discharge  an  irritating,  offensive,  purulent  matter.  This  vulvitis 
is  frequently  complicated  with  erythema,  ecthyma,  sometimes  with 
oedema,  erysipelas,  or  abscess.  It  is  principally  observed  during  preg- 
nancy, when  this  secretory  apparatus  is  very  active. 

In  a  variety  called  ^'  vulvite  folUeuleuse,"  by  Robert,  the  mucous  mem- 
brane of  the  vestibule  and  that  covering  the  interior  of  the  crypts  only 
are  affected.  The  mucous  crypts  present  at  their  orifices  a  vivid  red 
areola;  their  cavities  inclose  a  droplet  of  pus,  which  can  be  squeezed 
out.  This  vestibular  vulvitis,  Robert  says,  is  always  more  or  less 
allied  to  urethral  blennorrhagia. 

Treatment. — The  inflammatory  forms  or  complications  of  pruritus 
are  best  treated  by  soothing  applications.  Oxide  of  zinc,  oxide  of  bis- 
muth. Fuller's  earth,  in  ointment  or  lotion,  or  mixed  with  glycerin, 
are  especially  useful.  I  have  seen  the  most  satisfactory  result  from 
the  linimentum  calcis  applied  on  strips  of  lint. 

The  local  treatment  must  first  of  all  be  directed  to  prevent  the  affected 
surfaces  from  lying  in  contact,  and  from  chafing.  The  dependent  ab- 
domen must  be  well  supported  by  an  abdominal  belt.  The  labia  must 
be  guarded  from  the  groins  and  thighs  by  interposing  shreds  of  lint 
soaked  in  glycerin  and  bismuth,  in  lead-lotion,  in  the  lime-liniment, 
in  glycerin  of  borax,  in  a  solution  of  cyanide  of  potassium  in  glyc- 


760  DISEASES    OF    THE    VULVA. 

erin ;  or  sometimes  alkaline  solutions  of  potash  or  soda  are  very  effec- 
tive j  weak  solutions  of  creasote  or  carbolic  acid  are  useful  in  some 
cases.  When  small  pustules  form,  painting  the  surface  over  with  a 
solution  of  nitrate  of  silver,  a  drachm  to  the  ounce,  is  often  very  use- 
ful; it  sometimes  allays  pain  in  a  remarkable  manner. 

Constitutional  treatment  is  often  of  the  greatest  importanee.  It  is 
necessary,  in  the  first  place,  to  remove,  if  we  can,  any  complicating, 
local,  or  general  disease.  In  women  who  have  reached  the  climacteric, 
in  whom  there  is  probably  a  gouty  or  lithic  acid  diathesis,  strict  atten- 
tion must  be  paid  to  the  correction  of  this  state.  Alteratives,  mercu- 
rial salines,  alkalies,  aloes,  colchicum,  podophyllin,  taraxacum,  are 
often  indicated.  The  peculiar  nervous  condition  of  the  climacteric  age 
must  be  studied.  Bromide  of  potassium  in  large  doses  is  of  essential 
service.  Digitalis  and  aconite  are  useful.  Sometimes  we  are  com- 
pelled to  resort  to  more  decided  narcotics,  as  opium  or  chloral. 

When  clear  urine  and  well-acting  bowels  indicate  that  the  blood  is 
comparatively  freed  from  lithic  acid  and  other  impurities,  tonics  as  bark 
or  quinine  are  often  useful.  Gueneau  de  Mussy  insists  that  a  gouty  or 
other  diathesis  is  often  present.  He  advises  the  use  of  small  doses  of 
arsenic.  Such  patients  should  avoid  stimulants,  especially  beer;  and 
moderate  exercise  in  the  open  air  should  be  enjoined. 

When  the  inflammatory  condition  is  subdued,  we  may  try  in  succes- 
sion a  variety  of  local  measures.  Gueneau  de  Mussy  recommends  the 
following  means :  Emollient  baths  containing  poppy,  or  laurocerasus, 
belladonna,  aconite,  or  pulverized  water  with  belladonna;  a  weak  solu- 
tion of  bichloride  of  mercury,  alkaline  washes,  glycerin  with  calomel, 
tannin  or  benzoin.  Intra- vaginal  washes  of  decoctions  of  rice  and 
poppy-heads  are  useful.  In  the  chronic  form,  strong  sulphur  baths, 
some  hyposulphite  baths,  as  those  of  Aix,  pomades  with  mercury  and 
belladonna,  carbolic  acid  lotions,  come  into  use.  But  we  must  be  pre- 
pared to  find  some  cases  for  a  long  time  rebellious  to  all  treatment. 

The  pruritus  of  pregnancy  is  associated  with  the  exalted  centric 
nervous  irritability  developed  by  pregnancy,  and  with  the  increased 
local  afflux  of  blood.  Leucorrhoea  generally  attends,  and  the  vascular 
fulness  exceeds  the  usual  degree.  Saline  purgatives,  as  Piillna  or 
Friedrickshall  water;  alkaline  baths,  as  Vichy,  which  can  be  prepared 
at  home,  or  even  bathing  with  plain  cold  or  tepid  water,  constitute  the 
best  palliatives.  Salines  and  colchicum  may  be  indicated.  Bromide 
of  potassium  may  be  useful. 

Amongst  the  acquired  abnormities  is  hypertrophy,  which  sometimes 
assumes  a  monstrous  appearance.  It  occurs  as  elephantiasis,  and  con- 
sists in  increase  of  volume  of  the  cutis  and  subcutaneous  connective 
tissue.  It  affects  the  entire  vulva,  or  only  a  part,  as  the  nymphse,  or 
the  labia  raajora,  or  the  clitoris.  The  mass  thus  formed  may  attain 
the  M'cight  of  several  pounds.  The  surface  of  the  enlarged  part  is 
smooth,  or  rough  from  irregular  growth  of  epidermis,  generally  warty, 
uneven,  lobulated.  In  these  cases  the  tumor  reproduces  all  the  marked 
characters  of  tlio  papillary  growth,  and  resembles  the  condyloma.  In 
its  substance  it  consists  of  dense  fibrous  connective  tissue.  Often  the 
hypertrophy  spreads  upwards  over  the  mons  Veneris,  and  backwards 


CYSTS.  761 

over  the  perineum.  Frequently  the  mass,  under  traction  of  its  own 
weight,  becomes  pedunculated,  and  its  removal  is  then  easy.  I  haye 
known  the  labia  minora  enlarged  so  as  to  form  flaps  hanging  down 
below  the  labia  majora  to  be  a  source  of  trouble,  especially  during  the 
menstrual  periods,  when  they  swell  from  congestion,  and  by  chafing 
against  each  other  produce  irritation  and  leucorrhoea. 

Atrophy  of  the  labia  occasionally  follows  chronic  syphilitic  affections 
of  the  vulva,  attended  by  progressive  cicatricial  formations. 

The  clitoris  is  subject  to  abnormal  enlargement.  This,  says  Roki- 
tansky,  is  more  often  congenital  than  acquired.  This  is  one  of  the  condi- 
tions which,  especially  when  conjoined  with  excessive  development  of  the 
nyraphse,  as  is  often  the  case,  simulates  hermaphroditism.  The  glans 
may  be  very  large,  and  the  prepuce  so  developed  as  to  resemble  a 
penis,  whilst  the  enlarged  nympha^  assume  the  appearance  of  a  scrotum. 
There  is  a  good  example  of  this  malformation  taken  from  an  infant  in 
St.  Thomas's  Museum. 

As  the  subject  of  hermaphroditism  has  little  clinical  interest,  I  must 
refer  those  who  seek  information  on  it  to  Rokitansky's  work.^ 

Little  tumors  are  sometimes  found  in  the  labia,  which  Huguier  has 
described  under  the  name  "  Endermojjtosis."  These  are  due  to  hyper- 
trophv  of  the  sebaceous  glands.  They  are  not  painful ;  they  give  vent 
on  squeezing  to  sebaceous  matter.  The  radical  cure  is  to  cut  them  out 
w^th  scissors. 

Neuromata  of  the  vulva  have  been  described  by  Simpson  as  sensitive 
points  and  structures  external  to  the  orifice  of  the  urethra,  and  as 
analogous  to  the  caruncles  of  this  part.  True  small  nodular. neuromata 
may  be  found  under  the  mucous  membrane  here  as  well  as  in  other 
parts  of  the  body.  They  are  the  occasion  of  much  suffering,  and  to 
obviate  this  the  removal  of  the  offending  nodules  is  necessary. 

Vascular  outgrowths  occur  as  teleangiectasis  in  the  labia  majora,  and 
as  the  vascular  excrescence  of  the  meatus  urinarius. 

Cysts  are  formed  sometimes  in  the  labia  majora,  and  may  attain  a 
large  size.  They  contain  a  serous,  synovia-like  colloid,  or  a  brown 
sanguineous  fluid.  Fatty  cysts  containing  hair  and  teeth  have  been 
observed.  Other  cysts  result  from  a  degeneration  of  the  vulvo-vaginal 
glands. 

Cystic  dilatations  are  also  formed  in  Bartholini's  glands  by  the 
occlusion  of  the  duct,  which  may  be  the  result  of  inflammation.  In 
this  case  it  is  probable  that  the  proper  glandular  structure  undergoes 
more  or  less  extensive  atrophy  or  degeneration.  The  cyst  forming  a 
tumor  which  enlarges,  the  labium  containing  it  becomes  the  centre  of 
inflammation,  swelling,  and  pain  in  this  and  the  surrounding  parts. 
The  treatment  consists  in  freely  incising  the  cyst,  and  dressing  the 
cavity  with  lint  soaked  in  tincture  of  iodine. 

Blood  effusions  or  thrombi  may  be  the  source  of  cysts  in  the  vaginal 
wall.  The  original  thrombus  may  have  been  overlooked.  A  woman 
aged  sixty  came  to  me  at  the  London  Hospital  for  metrorrhagia.  There 
was  a  sanguineous  effusion  in  the  left  labium  forming  a  considerable 
tumor. 

1  "Lehrbuch  der  Pathologischen  Anatomie,"  3d  ed.,  1861. 


762  DISEASES    OF    THE    VULVA. 

Cystic  swellings  of  the  labia  majora  have  come  under  my  notice 
accidentally  when  examining  on  indication  of  other  disease.  It  is 
therefore  certain  that  after  a  time  the  inflammation  and  distress  which 
are  usually  so  acute  at  first  may  subside,  and  tolerance  ensue.  The 
patients  have  become  unconscious  of  trouble ;  but  the  mere  enlargement, 
causing  more  or  less  occlusion  of  the  vulva,  must  occasion  some  annoy- 
ance.    In  these  cases  puncture  has  let  out  a  dirty  turbid  pus. 

The  tumors  or  outgrowths  of  the  vulva  are  so  w^ell  described  by 
McClintock  that  I  am  induced  to  follow  his  account.  He  classifies 
them  as — 1.  AYarty  and  hypertrophic ;  2.  Fibrous  and  fatty;  3.  Cystic; 
4.  Vascular;  5.  Cancroid  and  carcinomatous. 

The  labia  may  be  also  enlarged  from  effusions  of  blood  or  serum, 
from  the  presence  of  an  abscess  or  of  a  hernia,  or  from  elephantiasis. 

Warty  {syphilitic)  excrescences  may  grow  from  any  part  of  the  vulva, 
but  they  most  commonly  appear  around  the  orifice  of  the  urethra  or  of 
the  vagina  ;  in  this  latter  case  they  look  like  elongations  of  the  corpora 
myrtiformia.  They  are  usually  found  in  clusters,  but  sometimes  occur 
singly.  Often  three  or  four  grow  by  a  common  root.  Their  color  is 
nearly  w"hite,  and  their  structure  tolerably  firm.  They  are  ])robably 
always  of  syphilitic  origin.  They  seldom  cause  much  pain,  but  they 
cause  more  or  less  local  irritation  and  mucous  discharge. 

At  least  two  varieties  of  w^arts  are  met  with  on  the  vulva.  One  of 
these,  says  McClintock,  is  the  true  warty  excrescence,  the  verruca  or 
thymion  of  Celsus.  It  is  very  similar  to  the  warts  which  appear  on 
the  hands,  except  that  it  frequently  has  a  pedunculated  shape,  the  stalk 
or  neck  having  a  smaller  diameter  tlian  the  body  of  the  growth. 
When  of  large  size  they  are  apt  to  be  fissured  at  the  top,  and  to  bleed 
if  scratched  or  otherwise  hurt.  They  have  the  color  of  the  surrounding 
skin,  and  do  not  yield  any  discharge.  The  greater  labia  and  adjacent 
common  integument  are  the  parts  from  which  these  warts  generally 
spring.  Warts  of  the  other  kind  or  variety  grow  from  the  vestibulum, 
meatus  urinarius,  carunculse  myrtiformes,  or  some  of  the  parts  ordinarily 
concealed  within  the  vulvar  sinus.  Their  structure  is  firm,  but  they  are 
remarkably  pale  in  color  and  semi-transparent,  so  as  to  bear  much 
resemblance  to  the  white  muscular  tissue  of  fish. 

Considerable  hypertrophy  of  the  nymphse,  clitoris,  or  more  rarely  of 
the  labia  majora,  is  not  unfrequently  associated  with  these  warty  ex- 
crescences, a  circumstance  which  McClintock  suggests  strengthens  the 
probability  of  their  being  due  to  some  venereal  taint.  But  these 
enlargements  frequently  occur  when  there  are  no  warts,  and  they  may 
unquestionably  occur  where  there  is  no  syphilitic  taint.  The  syphilitic 
hypertrophy  is  generally  marked  by  a  rugous  warty  surface  ;  and  other 
evidence  of  syphilis,  either  historical,  or  still  impressed  upon  other 
parts  of  the  body,  as  the  skin  or  throat,  will  rarely  be  wanting.  Sur- 
geons are  familiar  with  the  mucous  or  gummous  tubercle  or  condy- 
lomata of  the  anus  in  syphilitic  patients.  Xot  unfrequently  the  anus 
is  affected  at  the  same  time  as  the  vulva,  and  then  the  syphilitic  nature 
of  the  vulvar  growth  is  at  once  recognized.  The  vulvar  gummous 
tubercle  greatly  resembles  that  of  the  anus.     See  Fig.  168,  p.  763. 

In  Bartholomew's  Museum  is  a  specimen,  No.  32.80,  of  a  large  fibro- 


SYPHILITIC    HYPERTEOPHY, 


763 


cellular  tumor,  which  was  attached  by  a  broad  pedicle  to  the  left  labium 
of  a  woman  aged  thirty-five.  It  had  existed  for  ten  years.  Three 
years  previous  to  its  removal  she  had  syphilis,  since  which  time  it 
rapidly  enlarged. 

These  growths  should  be  treated  in  the  same  manner  as  the  gum- 
mous  tubercle  of  the  anus.  In  the  early  stage  the  warts  may  some- 
times be  dispersed  by  astringent  and  caustic  applications ;  keeping  the 
parts  very  dry,  and  dusting  them  frequently  with  prepared  chalk,  or 
some  other  absorbing  powder,  will  occasionally  remove  them.  The 
syphilitic  growths  are  often  effectually  treated  by  frequent  powdering 
with  calomel.  A  very  effective  application  is  painting  with  strong 
acetic  acid.     This  has  seemed  to  me  even  better  than  nitric  acid. 


Sypliilitic  hypertrophy  of  left  nympha.    (From  MoClintock.) 


But  when  the  growths  have  attained  a  considerable  size,  extirpation 
by  knife,  scissors,  ecraseur,  or  galvanic  cautery  is  by  far  the  best  plan. 
When  cut  off  on  a  level  with  the  surrounding  raucous  membrane  they 
are  not  likely  to  be  reproduced ;  but  if  a  portion  of  the  base  or  stem 
be  allowed  to  remain,  this  is  very  apt  to  throw  out  fresh  shoots  or  pro- 
cesses. I  have  removed  a  very  large  mass  of  syphilitic  tubercle  of  the 
labia  at  an  advanced  stage  of  pregnancy,  on  the  ground  that  during 
labor  laceration  might  occur.  It  is,  I  believe,  under  all  circumstances, 
best  to  remove  them.  Should  hemorrhage  occur  after  ablation,  it  may 
be  restrained  by  pi^essure  with  or  without  perchloride  of  iron,  by  the 
actual  cautery,  or  still  better  by  acupressure.  Needles  transfixing  the 
bleeding  surface  and  twisted  sutures  will  effectually  stop  the  bleeding. 

Although  I  believe  the  syphilitic  excrescence  can  generally  be  dis- 
tinguished from  other  forms,  we  meet  in  practice  with  growths  which 
present  considerable  resemblance  to  them  where  there  is  no  room  to 
admit  the  complication  with  a  venereal  taint.  Dr.  West  is  undoubt- 
edly right  in  his  statement  that  some  of  these  belong  to  the  same  class 
as  lupus,  "and  are  quite  independent  of  venereal  taint,  and  of  these 


764 


DISEASES    OF    THE    VULVA. 


some  pass  by  gradations,  difiicult  to  seize,  into  the  same  class  with 
epithelial  cancer." 

To  these  forms  the  names  herpes  exedens,  lupus,  rodent  ulcer,  tertiary 
syphilis,  esthiomenus  (Alibert)  have  been  applied.  Huguier  adopts  the 
last.     Fig.  169,  from  McClintock,  represents  the  characters  of  lupus. 


Fig.  169. 


Hypertrophic  lupus  of  the  vulva.    (From  McClintock.) 

Cancer,  frequent  in  the  uterus,  rare  in  the  vagina,  again  becomes 
frequent  in  the  vulva. 

The  medullary  cancer  occurs  very  rarely  as  a  primary  disease  of  the 
labia.  It  is  most  commonly  a  propagation  of  the  disease  from  the  vagina 
in  association  with  cancer  of  other  organs,  and  especially  w'ith  medul- 
lary warts  in  the  skin  and  consecutive  cancer  of  the  inguinal  glands. 

More  frequent  is  the  epidermal  cancer  (cancroid),  which  appears  as  a 
proliferating  widely  spreading  degeneration  of  the  labia  or  clitoris. 
This  latter  organ  is  especially  prone  to  cancer,  and  like  the  same  dis- 
ease in  the  penis,  it  may  for  a  considerable  time  be  limited  to  the 
organ.  Owing  to  its  almost  external  position,  and  the  distress  which 
the  disease  and  attendant  enlargement  produce,  it  is  generally  detected 
early.  These  circumstances  make  ablation  especially  hopeful.  It  is  not 
wise  to  be  deterred  from  operating  even  when  there  is  evidence  of 
enlargement  of  the  inguinal  glands.  A  respite  of  comparative  ease 
may  at  any  rate  be  counted  upon.  The  operation  should  be  thorough. 
The  patient  is  placed  in  the  lithotomy  position.  The  diseased  part 
is  firmly  seized  by  a  curved   Museux's  forceps,  and  drawn   out   so 


EXCRESCENCE    OF    MEATUS     URINARIUS.  765 

as  to  put' its  attachments  upon  the  stretch.  With  strong  scissors  the 
mass  is  cut  away  close  to  the  pubic  bones.  Free  hemorrhage  is  likely 
to  follow.  This  may  be  restrained  by  the  actual  cautery,  or  by  very 
firm  pressure  by  compresses.  A  mode  of  proceeding  preferable  when 
the  diseased  mass  can  be  fairly  commanded  by  the  wire-loop,  is  the 
galvanic  cautery. 

Beginning  in  the  clitoris,  cancer  spreads  to  the  contiguous  structures, 
and  soon  invades  the  labia  minora  et  majora.  When  this  is  the  case, 
the  prospect  of  relief  by  operation  is  much  diminished.  Still  ablation 
by  knife,  ecraseur,  or  galvanic  cautery  may  in  some  cases  be  attempted. 

Where  ablation  has  to  be  abandoned,  we  must  fall  back  upon  caus- 
tics or  palliative  treatment.  All  the  measures  adopted  in  the  case  of 
cancer  of  the  uterus  find  application  here. 

In  St.  Bartholomew's  Museum  is  a  specimen  (No.  32.61)  of  melano- 
sis of  the  labia  and  vagina.  The  parts  were  removed  by  operation,  on 
account  of  a  large  mass  of  melanotic  disease  which,  arising  at  the  front 
part  of  the  vagina,  encroached  equally  upon  either  labium. 

In  the  same  museum  is  another  specimen  (No.  32.42)  of  a  labium 
on  the  surface  of  which  is  an  oval,  elevated,  warty  growth  of  moder- 
ately firm  texture,  and  with  a  finely-granulated  surface,  very  similar 
to  the  chimney-sweeper's  cancer  of  the  scrotum. 

The  vascular  excrescence,  or  tumor  of  the  meatus  urinarius.  This  is 
in  many  cases  an  outgrowth  from  the  mucous  membrane  of  the  urethra, 
most  commonly  found  at  the  meatus.  At  this  orifice  it  often  protrudes, 
bulging  out  as  a  small  tumor,  sometimes,  but  rarely,  as  large  as  a 
cherry.  When  it  so  bulges,  of  course  it  is  easily  seen,  and  so  it  has 
come  to  be  described  as  a  disease  of  this  particular  spot.  But  a  simi- 
lar condition  not  seldom  extends  a  little  distance  up  the  urethra.  The 
word  "  vascular "  gives  a  good  idea  of  its  appearance.  It  may  be 
roughly  described  as  an  outgrowth  of  vessels  loosely  held  together  in 
a  mass  by  a  little  connective  tissue,  and  covered  by  a  thickened  mucous 
membrane.  The  surface  is  irregular,  a  little  lobulated,  deep  red,  or 
blue-red.  It  is  soft,  difficult  to  seize  with  tenaculum  or  forceps,  it  so 
readily  breaks  down.  The  morbid  mass  and  appearance  are  generally 
bounded  by  the  margin  of  the  urethral  orifice,  that  is,  the  growth  seems 
to  be  peculiar  to  the  urethral  mucous  membrane ;  it  stops  abruptly  at 
the  mucous  membrane  of  the  vulva. 

M.  Quekett  examined  one  of  these  vascular  growths,  and  found  it 
to  be  composed  of  epithelial  cells,  and  a  number  of  capillaries  coming 
up  close  to  the  surftice.  This  explains  the  occasional  tendency  to 
bleeding.  Wedl,  in  his  Pathological  Histology,  describes  and  figures 
the  appearance  presented  by  the  urethral  caruncle.  He  regards  these 
bodies  as  "  dendritic,  papillary,  new  formations  of  connective  tissue." 
The  one  he  examined  was  of  a  somewhat  elongated  figure,  of  a  bluish- 
red  color,  and  spongy  texture,  and  exhibited,  when  cut  into,  cavities 
containing  colloid  matter.  The  most  interesting  point  was  the  dis- 
tribution of  the  bloodvessels,  which  could  be  very  distinctly  traced  in 
transverse  sections,  moistened  with  a  solution  of  sugar  or  common 
salt.  Their  ramification  precisely  resembled  that  seen  in  the  vasa  vor- 
ticosa.     Several  vessels  of  considerable  size,  entering  one  of  the  lob- 


766  DISEASES    OF    THE    VULVA. 

nles,  divided  into  a  multitude  of  smaller  ones,  which,  though  not  of 
capillary  dimensions,  made  numerous  undulating  curves,  extending  up 
to  the  periphery  of  the  lobule,  where  they  terminated  in  mostly  short 
and  abrupt  loops.  The  walls  of  these  vessels  were  everywhere  simple, 
like  those  of  capillaries.  There  were  extravasations  of  blood  at  several 
points,  of  old  and  recent  occurrence.  The  late  Dr.  John  Reid  exam- 
ined for  Sir  J.  Simpson  a  very  sensitive  and  painful  caruncle,  and  came 
to  the  conclusion  that  there  was  a  very  rich  distribution  of  nervous 
filaments  in  it.  It  seems,  in  many  cases,  to  be  analogous  to  hemor- 
rhoids in  the  anus. 

It  is  most  frequent,  according  to  my  observation,  in  women  who 
have  reached  the  climacteric,  or  passed  it,  and  who  have  been  married. 
But  it  is  found  occasionally  in  girls  and  young  women,  single  or  mar- 
ried. There  is  a  tendency  to  venous  hsemostasis  in  the  pelvic  organs, 
especially  in  the  mucous  membrane  of  women  advancing  in  years, 
which  appears  to  me  to  predispose  to  these  irregular  vascular  protu- 
berances. The  excrescence  may  be  "gummous."  At  least  I  have  seen 
cases  connected  with  secondary  syphilis.  And  Scanzoni  believes  they 
result  from  chronic  urethritis.  In  many  instances  there  is  a  previous 
history  of  gonorrhoea. 

The  principal  symptom  of  the  disease  is  acute,  agonizing  pain  on 
micturition,  compelling  the  sufferers  to  postpone  the  inevitable  torture 
by  submitting  as  long  as  they  can  to  retention  in  the  bladder.  Hence 
there  is  a  retrograde  risk  of  inflammation  of  the  mucous  membrane  of 
the  bladder,  and  distension.  Not  uncommonly  a  little  blood  is  passed 
with,  or  after  the  urine;  and  bleeding  may  occur  at  other  times,  as 
from  rubbing  to  ease  the  pain,  friction  in  walking,  and  sexual  inter- 
course. Dyspareunia  is  almost  a  necessary  consequence.  Often  there 
is  a  muco-purulent  discharge  from  the  urethra  and  from  the  vagina, 
which  may  be  an  accidental  complication.  Pains  in  distant  parts  seem 
to  take  their  rise  from  this  local  disease  as  reflex  or  sympathetic  phe- 
nomena. 

It  may  give  rise  to  the  suspicion  of  stone  in  the  bladder.  The  con- 
stant pain  exhausts  the  nervous  force,  inducing  prostration  and  disor- 
der of  the  functions  of  other  organs.  The  real  source  of  the  mischief 
is  often  long  overlooked  by  those  who  neglect  the  prime  clinical 
maxim  of  making  a  direct  examination  of  the  part  which  is  the  central 
seat  of  pain. 

The  diagnosis  is  made  out  by  taking  the  indication  furnished  by 
subjective  sensations  as  the  guide  to  objective  exploration.  The  pa- 
tient lying  on  her  side,  the  upper  labium  is  drawn  up  so  as  to  expose 
the  structures  of  the  vestibulum,  when  the  angry-looking  orifice  of  the 
urethra  will  be  seen.  By  passing  a  catheter  gently  we  gain  informa- 
tion as  to  the  state  of  the  urethra  beyond  the  meatus.  And  it  is  often 
useful  to  dilate  the  urethra  with  a  Weiss's  dilator,  or  the  excellent  in- 
strument contrived  by  Dr.  Emmet  for  dilating  the  cervix  uteri. 

The  treatment  consists  in  destroying  the  offending  growth.  This  may 
be  done  more  or  less  successfully  by  various  methods.  Where  there 
is  much  irritation,  and  the  patient  declines  to  submit  to  operation, 
some  relief  may  be  had  from  lead  lotion,  or  poppy-head  fomentations. 


COCCYGODYNIA.  767 

Simpson  speaks  highly  of  an  ointment  consisting  of  two  drachms  of 
hydrocyanic  acid  to  an  ounce  of  lard.  A  bit  of  this  the  size  of  a  pea 
is  applied  to  the  part  three  or  four  times  a  day.  Aconite  and  chloro- 
form ointments  are  also  useful.  But  things  of  this  kind  can  only  be 
sanctioned  as  temporary  and  trivial  palliatives.  If  the  tumor  present 
a  distinct  polypoid  form,  it  may  be  removed  by  a  ligature,  by  snaring 
it,  and  cutting  through  its  base  by  a  fine  wire  ^craseur,  or  by  snipping 
off  with  scissors.  Excision  is  better  than  the  ligature.  The  tumor 
must  first  be  seized  with  a  small  hook  or  forceps,  and  lightly  drawn 
out,  so  as  to  enable  the  scissors  to  get  well  at  the  base.  Some  bleeding 
usually  follows,  but  compression  with  a  bit  of  lint  steeped  in  solution 
of  perchloride  of  iron  will  soon  stop  it.  Still  these  troublesome 
growths  are  very  apt  to  recur.  There  seems  an  active  germinating  or 
proliferous  property  in  the  mucous  membrane  from  which  they  rise,  so 
that  the  smallest  particle  left  retains  the  property  of  reproducing  the 
disease.  Mere  excision,  says  Richet  (Gaz.  des  Hop.,  1872),  will  not 
remove  the  contraction  and  hypertrophy  of  the  urethra,  which  often 
give  rise  to  the  most  painful  symptoms.  To  effect  this  he  advises  for- 
cible dilatation  of  the  urethra. 

I  have  applied  nitrate  of  silver  repeatedly,  always  with  good  effect 
for  a  short  time,  although  causing  great  pain  at  the  moment  of  appli- 
cation. I  have  also  used  potassa  cum  calce,  nitric  acid,  and  other 
caustics,  all  with  more  or  less  advantage.  But  the  best  plan,  I  believe, 
is  to  touch  them  with  the  actual  cautery,  either  the  hot  iron  or  copper, 
or  the  galvano-caustic  wire  or  button.  Cold-water  dressing  should  be 
applied  after  the  operation,  and  astringent  lotions  when  the  sloughs  have 
fallen. 

The  orifice  of  the  vagina  is  subject  to  fissures.  These  are  found  as 
linear  irritable  ulcers,  or  clefts  in  the  mucous  membrane.  The  most 
frequent  seat  is  the  posterior  commissure,  but  I  have  seen  them  at  the 
anterior  commissure.  They  are  sequelae  of  slight  lacerations  expe- 
rienced during  labor ;  they  have  been  produced  by  coitus,  and  have 
resulted  from  an  altered  condition  of  mucous  membrane,  the  result  of 
inflamraaticm,  especially  of  a  syphilitic  character.  As  fissure  of  the 
anus  is  a  source  of  pain  during  the  performance  of  the  functions  of 
this  part,  so  is  fissure  of  the  vagina  or  vulva.  It  may  be  chafed  and 
irritated  by  walking,  by  discharges,  by  a  drop  of  urine;  but  the  most 
distressing  symptom  is  dyspareunia.  The  painful  spot  may  be  detected 
by  digital  examination,  and  by  retracting  the  labia  it  may  be  brought 
into  sight. 

The  treatment  is  the  same  as  for  anal  fissure.  The  edges  may  be 
torn  open  by  the  fingers,  or  it  may  be  divided  by  the  knife.  But  the 
incision  should  not  be  deep,  lest  severe  hemorrhage  ensue.  It  is  enough 
to  make  a  shallow  incision  through  the  base  of  the  ulcer. 

Coocygodyma. 

This  disease  has  become  familiar  to  gynaecologists  through  the  writ- 
ings of  Sir  James  Simpson  ("Diseases  of  Women,"  1872,  vol.  ii, 
edited  by  A.  R.  Simpson).     But  Dr.  J.  C.  Nott,  of  New  York,  in  an 


768  COCCYGODYNIA. 

interesting  memoir  on  the  subject,  refers  to  two  cases  published  by 
himself  in  the  New  Orleans  Medical  Journal  fifteen  years  before 
Simpson's  first  communication. 

The  name  is  derived  from  coccyx  and  cdbvrj,  pain.  The  leading 
symptom  is  pain  in  the  region  of  the  coccyx  felt  by  the  patient  when- 
ever she  sits  down  and  rises,  and  sometimes  when  she  remains  in  a  sit- 
ting posture.  Most  of  the  patients  affected  with  it  are  obliged  to  sit 
on  one  hip,  or  with  only  one  side  resting  on  the  edge  of  a  chair,  or 
with  the  weight  partially  supported  by  a  hand  on  the  chair.  Some 
patients  dread  sitting  down.  There  are  other  movements  of  the  coccyx 
liable  to  be  attended  by  pain.  Thus,  patients  have  pain  with  every 
step  they  take,  whilst  in  others  walking  causes  no  uneasiness.  Others 
feel  the  pain  most  when  the  bowels  are  being  evacuated,  or  under  any 
circumstances  in  which  the  sphincter  or  levator  ani,  or  the  ischio-coccy- 
geal  muscles  are  called  into  action.  The  pain  is  not  in  every  case  very 
acute,  nor  at  all  times  equally  severe.  The  distinguishing  feature  of 
the  disease  in  every  case  is  that  the  pain  is  felt  at  the  low^est  part  of 
the  spine,  or  rather  in  the  seat  of  the  coccyx,  and  where  pressure 
always  aggravates  it.  Pressure  and  movement  of  the  coccyx  too,  with 
the  finger  in  various  directions,  produce  pain,  and  the  kind  of  move- 
ment which  is  then  attended  with  suflFering  differs  in  different  cases. 

Simpson  believes  the  pain  is  due  to  inflammation  of  the  coccygeal 
joint,  or  other  morbid  change,  wdien  any  action  of  the  muscles  in  con- 
nection with  it,  by  moving  the  joint,  produces  pain. 

We  might  naturally  look  for  the  origin  of  this  disease  in  some  injury 
of  the  part;  and  in  a  considerable  proportion  of  cases  injury  can  be 
traced.  But  it  is  remarkable  that  the  disease  occurs  in  the  unmarried, 
and  where  no  history  of  injury  can  be  made  out.  I,  myself,  have 
known  several  aggravated  cases  follow  labor.  In  these  I  cannot  doubt 
that  the  joint  received  injury  during  the  passage  of  the  child's  head. 
In  some  cases  we  know  the  sacro-coccygeal  joint  is  anchylosed,  the  tip 
of  the  coccyx  projecting  so  much  forwards  as  to  form  an  angle  with 
the  lower  part  of  the  sacrum.  The  anchylosis  is  likely  to  give  way 
during  labor.  And  where  there  is  no  anchylosis,  as  the  head  emerges, 
the  coccyx  may  be  felt  to  be  stretched  very  much  backwards,  and 
under  the  strain  some  of  the  fibres  of  the  anterior  ligaments  wdiich 
bind  this  bone  to  the  sacrum  may  be  torn,  and  in  the  joint  thus  ex- 
posed and  injured  inflammation  is  very  apt  to  be  set  up.  Simpson  saw 
abscess  follow. 

The  coccyx  again  is  liable  to  fracture  or  dislocation  from  direct 
violence,  as  from  a  fall  on  the  seat.  Patients  have  complained  that 
'^a  bone  growls  in,"  and  so  it  is  found.  It  is  also  liable  to  malforma- 
tions, to  deficient  development,  to  tumors,  and  even  double  monstrosity 
by  inclusion. 

But  in  a  certain  proportion  of  cases  no  local  lesion  can  be  made  out, 
and  we  are  driven  to  conclude  that  the  disease  is  a  neurosis,  a  form  of 
neuralgia,  the  expression,  perhaps,  of  some  remote  morbid  condition. 
But  latterly  some  new  light  seems  to  be  cast  upon  these  more  anoma- 
lous cases.  In  Virchow's  Archiv,  1860  (Die  Steissdriise  des  Menschen), 
Luschka  gives  an  account  of  a  small  gland  situated  just  at  the  anterior 


COCCYGODYNIA.  769 

end  of  the  coccyx  ;  it  is  in  immediate  relation  with  the  hindermost  part 
of  the  levator  ani,  and  is  connected  with  filaments  from  the  ganglion 
impar  of  the  sympathetic  nerve,  and  with  small  branches  of  the  middle 
sacral  artery,  between  the  levator  ani  and  the  posterior  end  of  the  ex- 
ternal sphincter.  The  gland  is  rich  in  nerves,  which  form  a  network 
perforating  its  stroma. 

This,  the  "  glandula  coccygea,"  Luschka  says,  is  probably  the  seat 
of  the  hygroma  cystica  periuealea.  And  when  we  consider  its  highly 
vascular  and  nervous  elements,  and  its  position,  we  can  hardly  doubt 
that  it  may  in  some  cases  be  the  seat  of  coccygodynia. 

Some  cases  called  coccygodynia  I  have  found  to  be  due  to  fissure  of 
the  anus,  and  to  the  conditions  which  induce  the  spasmodic  action  of 
the  vulvar  and  perineal  muscles,  and  known  as  "  vaginismus."  I  have 
also  traced  it  to  retroflexion  of  the  uterus. 

The  diagnosis  is  made  out  by  local  examination.  The  forefinger 
introduced  into  the  rectum  is  applied  to  the  inner  aspect  of  the  sacro- 
coccygeal joint,  wdiilst  a  finger  of  the  other  hand  is  applied  to  the  outer 
aspect.  The  bones  and  the  joint  thus  embraced  between  the  two  fingers 
are  completely  explored,  and  the  seat  of  pain  and  the  condition  of  the 
parts  are  easily  determined. 

The  treatment,  according  to  Simpson,  is  surgical.  But  I  have  met 
with  cases  which,  after  long  and  intense  suffering,  got  well  spontane- 
ously, or  when  uterine  disease  and  general  disorder  were  removed.  At 
the  same  time,  I  am  satisfied  that  surgical  treatment  is  occasionally 
essential  to  relief.  One  may  exhaust  sedatives,  neurotics,  and  tonics, 
and  still  the  pain  persists.  When  there  is  evident  inflammation,  leeches 
will  be  serviceable,  followed  by  counter-irritation.  Temporary  ease 
may  be  obtained  by  the  local  subcutaneous  injection  of  morphia.  The 
surgical  treatment  is  to  completely  separate  from  the  coccyx  the  mus- 
cular and  tendinous  fibres  that  are  in  connection  with  it.  This  is  done 
by  a  tenotomy-knife  passed  under  the  skin  at  a  short  distance  from  the 
tip  of  the  coccyx,  and  made  to  shave  along  the  posterior  aspect  of  the 
bone,  and  then  to  divide  the  muscular  and  tendinous  attachments,  first 
on  one  side,  then  and  lastly  all  round  the  tip  of  it.  It  is  not  in  every 
case  necessary  to  make  the  division  so  free.  In  some  instances  the 
division  of  the  fibres  of  the  gluteus  maximus  of  one  or  the  other  side, 
or  detachment  from  the  coccyx  of  the  sphincter  and  levator  ani  may  be 
enough.  No  bleeding  attends  the  operation,  which  possesses  also  the 
other  advantages  of  subcutaneous  sections.  Simpson  admits  that  this 
operation  occasionally  fails,  and  that  he  consequently  suggested  the 
removal  of  the  coccyx. 

Dr.  J.  C  Nott  prefers  extirpation  of  the  bone.  Simpson's  subcu- 
taneous incision  around  the  coccyx  would  divide  the  nervous  branches 
which  supply  Luschka's  gland,  and  in  this  way  its  success  in  some 
cases  may  be  explained. 


49 


i 


INDEX   OF   AUTHORITIES. 


Adams,  W.,  hook  for  peritoneum,  340 

Addison,  rupture  of  ovar.  turn.,  299 

Aetius,  sterility  from  contracted  os  ut.,  205 

Aitkin,  L.,  danger  of  sponge-tent,  208;  has- 
matocele,  625 

Alibert,  on  diagnosis,  66;  "  esthiomenus," 
763  ;  menstr.  and  skin  disease,  250 

Allbutt,  C  ,  premature  raenstr.,  154 

Altstiidter,  conium  to  stop  lactation,  417 

Amussat,  artificial  route  to  distended  ut.,  178, 
189;  fibroid  of  ut.,  671 

Anderson,  A.,  tubo-ovar.  cyst,  284;  keeping 
open  ovar.  cyst,  334 

Aran,  axis  of  ut.,  38;  abnormalities  of  men- 
str., 172  ;  aloetic  enemata,  471  ;  catheter 
for  diagnosis  in  chronic  metritis,  478  ;  diag- 
nosis of  morbid  from  healthy  follicles,  264  ; 
peritonitis  in  chronic  oophoritis,  267  ;  sup- 
puration of  ov.  and  tubes  from  menstr.  dis- 
turbance, 353  ;  endometritis,  46 1  ;  death 
from  cauterization  of  os  ut.,  467  ;  pelv. 
hsemat.,  604,  508,  526  ;  perimetric  inflam., 
5UI  ;  acute  metritis,  447  ;  ulcer,  in  chronic 
endometritis,  46  1 

Aristotle,  on  catamenia,  146 

Arnott,  Henrj',  histology  of  cystic  turn,  of  ov., 
282;  of  polypus  ut.,  683;  cancer  ut.,  705; 
epithelioma,  708;  sarcoma,  713;  fungosi- 
tifs,716 

Arnott,  James,  cold  in  cane,  736 

Ashwell,  diagn.  of  cane,  ut.,  721 

Atlee,  W.  L.,  ovar.  turn,  not  admitting  of 
detachment  of  cyst,  345  ;  ovariotomy  during 
gest.,  348 

Atthill,  L.,  nitric  acid  in  ut.  surgery,  470, 
475,  736  ;  fibroid  of  ut,  670 

Aveling,  atresia  vag.,  186 ;  double  metro- 
tome, 210;  hernial  gest.,  394;  inversion 
of  ut.  626  ;  polyptome,  691  ;  vesico-vag. 
fist,  747 


Babington,  urine  in  dis.  kidneys,  315 
Bacchetti,  electricity  in  tubal  gest.,  371 
Baedeker,  leuoin  in  ov.  turn.,  288 
Baillie,   absence   of  fimbriae    of  tubes,    110  ; 

dermoid  cysts  of  ov.,  2  90  ;   dropsy  of  F.  t, 

356;  fibrous  turn,  of  ov.,  274;  fibroid  turn. 

of  F.  t.,  351;  scrofulous  ov.,   269;  fibroid 

turn,  of  ut. ,  654 
Bainbridge,  subcutan.  incision  into  ov.  tum.. 

336 
Baker,  amput.  of  inverted  ut.,  634 
Bantock,  pepsin  in  cane.,  735 
Barba,  amput.  of  inverted  ut.,  634 


Barker,  Fordyce,    quinine  an  oxytocic,  170; 

endometritis,  460 
Barlow,  pelvic  hasmat.  and  purpura,  523 
Basedow,    drawing  off  liquor   amnii  through 

vag.,  372 
Basset,  blood  from  nipples,  156 
Bassius,  periodicity  of  leucorrhoea,  74 
Battye,  Mr.  R.  F.,  ovarian  turn.,  sudden  death 

from  asphyxia,  295 
Baudeloeque,    A.    C,   duct  of  Gaertner,    29  ; 

excision  of  cerv.  ut.,  728 
Bayle,  caustics  in  ennc.  ut  ,  733 
Beau,  Le,  early  menstr..  154 
Beclard,  rupture  of  ut.,  182 
Beck,  Snow,  nerves  of  ut.,  55;   arrested  invo- 
lution of  ut.,  410 
Beequerel,  pelvic  haemat  ,  507  ;  cane,  ut.,  723 
Begin,  procuring  adhesion  between  ovar.  cyst 

and  abdom.  walls,  335 
Bell,  John,  practicability  of  ovariotomy,  336 
Benporath,  fibroid  of  ut. ,  and  decay  of,    653  ; 

cane,  ut.,  716 
Bennet,  H.,  axis  of  ut,  38  ;  isthmus  ut.,  206  : 
neuralgic  dysmen.,  194;   ovar.  pain  sign  of 
inflam.  of  ut.,  99;  soft  bougies,  123;  death 
from  injecting  ut. ,  464  ;   endometritis,  455  ; 
metritis.  441,  443  ;  ovar.  pain,  413  ;  potassa 
cum  calce,  451  ;  cancer  ut.,  721 
Berard.  vascular  polypus  of  ut. ,  686 
Bernutz,  dysmenor.  from  obstruction  of  F.t., 
224;   membranous  dysmenor.,  226;    pelvic 
haemat,    504,      607,    619.    520,    523,    529; 
perimetric  inflam.,  483,  et  seg. 
Bernutz  and  Goupil,  tubercle  of  ov.,  269 
Beronius,  puncture  of  distended  half  of  bifid 

ut.,  178 
Berry,  removal  of  ovarian  cyst  through  rup- 
tured vag. .  304 
Bickersteth,  fibroid  of  ut,  673 
Billroth,  fluxion,  424 
Bird,  Golding,  electricity  in  amen.,  169  ;  cil- 

culus  in  prolaps.  ut. ,  638 
Bischoff,  changes  in  ov.   at  puberty,  27  ;  im- 
pregnation  in  ov.,    375;   menstr.,    28,    and 
periodicity  of,  147;  sterility,  109 
Blachet,  extra-uterine  £;est.,  787 
Blainville,  De,  on  duct  of  Gaertner,  29 
Blundell,  treatment  of  ovar.   turn.,   335  ;  ex- 
tirpation of  ut.  in  cane,  730 
Bockenthal,  inversion  of  ut. ,  630 
Bohmer.  hydrorrhoea  gravidarum,  84 
Boinet.  dropsy  of  F.  t.,  356  ;  iodine  in  amenor., 
168  ;  tapping,  iodine  inject,  into  ovar.  cysts. 
332;   tubo-ovar.  cysts,  285;  gastrotomy  for 
fibroid  of  ut  ,  675 


772 


IISTDEX     OF    AUTHORITIES. 


Boivin  and  Duges,  oophoritis,  259  ;  ovarian 
hernia,  e.  u.  gest..  254  ;  tuboovarian  cysts, 
284;  prolapsus  ut.,  537;  tubercle  of  ut. , 
696 

Borggreve,  inversion  of  ut. ,  630 

Bouillaud,  heemat.  from  variola,  523 

Boulard,  axis  of  ut.,  39;  nerves  of  ut.,  55. 
56;  calibre  of  isthmus,  206 

Bozeman,  vesico-vag.  fist.,  748 

Braun,  G.,  incision  of  cerv.,  214;  arsenic  in 
membranous  dysmen. ,  233;  hasmat.,  508; 
placental  polypus,  686   . 

Breisky,  bifid  ut.,  178  ;  normal  ut.,  33 

Breslau.  polypi  in  F.  t. ,  367;  physicians  of, 
on  epidemicity  of  leucor.,  74  ;  pelv.  hsemat., 
529 

Brierre  de  Boismont,  menstr.  in  hot  climates, 
150,  151 

Bright,  urine  in  dis.  kidneys,  315;  death 
from  collapse  in  of  ovar.  turn.,  295  ;  malig- 
nant or  scrofulous  disease  of  ov.,  274  ;  tho- 
racic and  abdominal  p.ithology,  311 

Briquet,  pain  in  ilium,  220 

Bristowe,  elongation  of  cerv.  ut.,  313;  per- 
forations of  ovar.  cysts,  301  ;  tubercul.  of 
ov.  269,  270  ;  ulcer,  of  intestine  opening 
into  ov.  cyst.  302;  effects  of  fibroids  of  ut., 
658 

Broadbent,  acetic  acid  in  cane,  733 

Broca,  labia  mnjora,  62  ;  diagn.  of  cane.  ut. , 
722 

Brodie,  B..  peritonitis  from  blood  escaping 
through  F.  t.,  182,  520  ;  operating  during 
Brighfs  dis..  337 

Brooke.  Ch.,  vesico-vaginal  fist,  and  lacera- 
tion of  perineum,  747,  748 

Brown,  Baker,  excision  of  part  of  ovarian 
cyst,  335;  prolaps.  ut.,  oper.  for,  573; 
fibroid  of  ut.,  669,  673  ;  vesico-vag.  fist., 
749 

Browne,  Chrighton,  influence  of  mind  on  ut. 
and  ov.,  236,  247 

Bruce,  A.,  sarcoma,  714 

Burd,  ovariotomy  in  pregn.,  348 

Burdach,  menstr.  in  hot  countries,  150 

Burow,  chlorate  potash  in  cane,  737 

Byrne,  J.  A.,  nitric  acid  in  uterine  surgery, 
470 

Callender,  recurrent  fibroid  of  ut.,  652 
Campbell,   puberty  in  Siam,   152;  extra-ute- 
rine gest.,  365 
Canestrini,  extra-uterine  gest.,  391 
Carswell,  erectile  tum.  of  ut.  652  ;  atrophy  of, 

652;  tubercle  of,  697 
Cnseaux,  length  of  vaginal-portion,  41 
Caspar,  J.  L.,  inversion  of  ut  ,  622 
Cayley,  sarcomii,  714 
Chadwick,  post,  colporrhaphy,  574 
Chairou,  compression  of  left  bv..  221 
Chalice,  brain  matter  in  ovarian  cysts,  290 
Chambers,  T.,  cautery  clamp,   343  ;  pruritus 
vulvae,   251  ;  adhesion   between   ovar.    cj'st 
and  abdom.  wall,  335 
Chambon,  tubo  ovarian  cysts,  284 
Champonniere,  Lucas,  lymphatic  ganglion  of 

ut.,  54 
Charcot,  pressure  on  ov.  region,  220 
Chaussier,  mucous  membrane  of  ut.,  50 
Chegoin,  uterine  abscess,  440 
Chomel,    colpitis,    739  ;    examination    of  pa- 
tients, 66 


Churchill,  dysmenor.  membran.,  226 

Cintrat,  fibroid  of  ut.,  674 

Clapton,  effects  of  disease  on  menstr.,  243 

Clarke,  C.  M.,  corroding  ulcer  of  ut.,  453 

Clarke,  C.  M.,  and  John,  cauliflower  excres- 
cence, 710 

Clarke,  John,  rodent  ut. ,  710;  vicarious 
haemor.,  156 

Claudius,  on  Douglasian  sac,  41 

Clay  Charles,  cautery-clamp,  343  ;  fibroid  of 
ut.,  673 

Clemensen,  inversion  of  ut.,  622 

Cloquet,  hypertr.  of  cerv.  ut.,  542 

Cockburn,  quinine  causes  abort..  170 

Cockle,  death  from  fibroid  ut.,  681 

Cohnstein,  intra-ut.  medication,  467 

Coindet,  iodine  in  amenor.,  168 

Comstock,  Dr.,  inversion  of  ut.,  623 

Cnnolly.  on  insanity,  235 

Cook,  foBtal  bones  in  cancer  ut.,  717 

Cooke,  T.  C,  inverted  ut.,  torn  away,  622 

Cooper,  H. ,  rupture  of  ut.,  511 

Cooper,  Sir  A.,  early  menstr.  153 

Cooper,  S. .  cancer  of  ut..  702,  719;  diagn. 
by  ut.  sound,  122;  inversion  ut.,  627; 
procid.  gravid  ut.,  560 

Coste,  cause  of  e.  u.  gest.,  369;  corpora 
lutea,  24:  development  of  ut.  muc. 
membr.,  227;  impregnation  in  ov.,  375; 
periodicity  of  menstr.  and  appearances  in 
ov.,  147  ;  source  of  menstr.  blood,  150 

Courty,  absence  of  ut.  cavity,  110  ;  cancer  of 
ov  ,  271  ;  chronic  fluxion,  425  ;  eczema  of 
cerv.,  437;  hydro-therapeutics  and  tar- 
water  in  leucor.,  81  ;  membranes  passed 
though  hymen  existed,  229  ;  pelv.  cellu- 
litis, 480  ;  revulsion  in  fluxion,  427  ;  vag- 
inismus, 104,  106 

Cowper,  vulvar  gland,  64 

Crosse,  inversion  of  ut. ,  615,  618,  623 

Cruveilhier,  calculus  in  prolaps  ut. ,  538; 
cane,  of  prolaps.  ut.,  560;  cane,  ut.,  702; 
fibrous  turn,  of  ov.,  274;  fibroid  tum.  of 
ut.,  640,  656,  661  ;  hydrorrhoea  gravid- 
arum, 84  ;  hypertr.  of  cerv.  ut.,  542  ;  in- 
terstitial gest.,  390;  nerves  and  vessels  of 
ut.,  53,  55  ;  OS  tincEe,  42  ;  round  ligament, 
35;  prolaps.  ut.,  535;  vascular  polypus 
ut.,  686 

Curling,  sterility  in  man,  115,  254;  fibroid 
of  vag.,  752 

Czihak,  extra-uterine  gest..  391 

D'Andrade,  vicarious  bleeding,  156 

Dance,  vascular  pol.  ut. ,  686 

Davis.   R.   A.,    menstr.   and   mental  diseases, 

246 
Davis.  D.  D.,  inversion  of  ut..  621 
Davis,  H.,  amput.  of  inverted  ut.,  634 
De   Morgan,    cane,    ut.,    734 ;  diet  in    eanc, 

738  .     .     ■  . 

Deees,  retention  of  menstr.  fluid  in  bifid  ut., 

rupture,  178  ;    double  vag.,  523 
Delacroix,  excis.  of  cane.  cerv.  ut.,  728 
Delamotte,  hydrorrhoea  gravid.,  84 
Deleurye,  hydrorrhcea  gravidarum,  84 
Delpech,  gastrotouiy  in  e.  u.  gest.,  386 
Demarquay,    gastrotomy  for   fibroid    of    ut., 

675 
Deneux,  hernia  of  ov.,  254;  induces  adhesion 

between    ov.    cysts    and    abdominal  walls, 

335 


INDEX     OF    AUTHORITIES. 


773 


Denman,  inversion  of  ut.,  624 

Deville,  on  F.  t.,  30 

Dezeimeris,  extra-uterine  gest.,  378 

Dictionnaire  des  Sc.  Med.,  epidemicity  of 
leucor.,  74 

Dieffenbach,  prolaps.  ut.,  oper.  for,  572 

Dieulafoy,  aspirator-trocar,  608 

Disse,  ov.  cyst  in  fern,  hernia,  322  ;  recovery 
after  rupture  of  ov.  cyst,  298 

Doherty,  perimetric  inflain. ,  501 

Dolbeau,  retro-uterine  hasmat.,  519,  528,  531 

Donne,  menstr.  blood,  149  ;  Triciiomonas 
vaginalis,  72  ;  leucor.,  76  ;  vaginal  mucus. 
73 

Douglas,  folds,  sac  of,  36,  37 

Down,  L.,  menstr.  in  idiots,  171,  246 

Drejer,  extra-uterine  gest.,  391 

Dubois,  hydrorrhoea  gravid.,  84;  inversion  of 
ut. ,  625  ;  puncturing  by  rect.  for  occlusion 
of  ut. ,  191  ;  peritonitis,  191 

Ducbenne,  electricity  in  tubal  gest.,  372,  382; 
in  amenorrboea,  169 

Duncan,  M.,  bursting  of  ov.  cysts,  298  ;  diag- 
nosis of  suppuration  in  ov.,  266  ;  dilatation 
of  F.  t. ,  363  ;  fecundity,  fertility,  sterility, 
109  ;  ov.  cysts  on  external  surface  of  ut. 
in  cancer,  319  ;  resisting  power  of  ut. ,  150, 
181  ;  patency  of  F.  t.,  353  ;  ut.  sound 
passing  along  F.  t.,  142;  pelvic  inflam., 
488,  613;  pelvic  ha3mat. ,  529;  prolaps. 
ut.,  557 

Duparque,  gastrotomy  in  e.  u.  gest.,  381  ; 
diagn.   of  cane.  ut. ,  721 

Dupuytren,  amput.  of  hypertrophied  cerv. 
ut.,  110;  amput.  of  polypi,  691  ;  excision 
of  cane.  cerv.  ut.,  729 

Duverney,  ov.  gest.,  375  ;  vulvar  gland,  64 

Dyce,  abdominal  gest.,  &c.,  377 


Eade,  effects  of  fibroid  turn,  of  ut.,  659 
Edwards,  St.  John,  axial  rotation  of  ovarian 

turn.,   296 
Emmet,  prolaps.   ut.,   operation   for,  573  ;  in- 
version of  ut.,  620,  631  ;  excision   of  cerv. 
in  cane,  ut.,  731 


Faille,  B.  de  la,  interstitial  gest.,  389 
Farr,  W.,  fruitfulness  of  marriage,  109 
Farre,  A.;  peculiar  dis.  of  ov.,  266  ;   bursting 
of    hymen,    182;   P.    tube,    32;   ov.    gest., 
375  ;  casts  of  vag.,  230  ;  fungosities  of  ut., 
686 
Faye,  abscess  of  ov.  in  pregnancy,  265  ;  fibroid 

turn,  of  ut.,  640 
Fenerly,  pelvic  hssmat.,  504 
Ferber,  pelvic  hasmat.,  525 
Ferguson,  R.,  irritable  ut.,  193  ;  polypus  ut., 

682  ;  dysmenor.,  196,  226 
Fletcher,  stretching  of  vag.,  189 
Foek,  mortality  from  tapping  ov.  cysts,  330 
Follin,  axis  of  ut.,  38  ;  duct  of  Gaertner,  29  ; 

parovarium,  28 
Fontaine,  experim.  on  injecting  ut. ,  466 
Forbes,  J.  G.,  inversion  of  ut.,  627,  634 
Fox,    Wilson,    formation    of  cysts  in    ovary, 
281  ;  loculated  fibroid  of  ov.,  276  ;  ext.-ut. 
cyst,  361;  colloid  turn,  of  ov.,  284;  sarco- 
ma, 714 
FrankenhaUser,  nerves  of  ut.,  56 
Frairier,  pelvic  cellulitis,  480 


Fricke,  prolaps,  ut.,  oper.  for,  571 
Friedreich,   brain   matter   in   ov.   cysts,   290  : 

morphia  injections  in  tubal  cysts,  372 
Fritze,  e.  u.  gest.,  391 


Galen,  hysteria  and  lateriversion  of  ut.,  223 

Gallard,  pelv.  htemnt.,  504,  519  ;  expulsion 
of  cancerous  ut.,  718 

Galton.F.,   "  Hereditary  Genius,"  108,  109 

Gardien,  duct  of  Gaertner,  29 ;  gastrotomy 
in  e.  u.  gestation,  382,  385 

Gardner,  A.  K.,  on  pessaries,  565 

Gariel,  air  pessary,  666 

Gendrin,  causes  of  periodicity  of  menstr., 
147  ;   changes  in  ov.  at  puberty,  27 

Gentilhorame,  fibroid  of  ut.,  670 

Gerdy,  gastrotomy  in  e.  u.  gest.,  386  ;  poly- 
pus ut.,  680 

Gervis,  spontaneous  cure  of  ovarian  turn,,  297 

Gibbes,  dermoid  cyst  complicatipg  pregnancy, 
292 

Gibson,  procid.  ut.,  570  ;  in  oper.  for  prolaps. 
ut.,  676 

Giles,  pelv.  inflam.,  489  ;  latent  gonorrhoea, 
740 

Girdwood,  cause  of  periodicity  of  menstr., 
146  ;  changes  in  ov.  at  puberty,  27 

Goddard,  tapping  ovarian  cyst  in  pregnancy, 
349 

Godson,  C,  instrument  for  introducing  1am- 
inaria  tents,  207 

Gogarty,  fibroid  of  ut.,  670 

Gooch,  irritable  ut.,  193;  neuralgic  dys- 
menor., 196;  polypus  ut.,  689;  cauliflower 
excrescence,  710;  torpid  ut.,  237;  inver- 
sion of  ut.,  626 

Good,  Miison,  pseudoeyesis,  235 

Goodeve,  puberty  in  the  East,  152 

Gosselin,  endometritis,  461 

Goupil,  metrorrhagia  in  e.  u.  gest.,  364  ;  ova- 
rian gest.,  375  ;  pain  in  tubal  gest  ,  364  ; 
perimetric  inflam,,  483,  487  ;  pelvic  hsemat. , 
504 

Giaef,  hydrorrhoea  gravidarum,  84 

Graves,  leucor    and  vaginitis,  77 

Gray,  brain  matter  in  ovarian  cysts,  290  ;  poly 
pus  ut. ,  683 

Greenhalgh,  arrest  of  tubal  gest.  by  puncture, 
372  ;  double  metrotome,  209  ;  mod.  of 
Hodge's  pessary,  668 

Grimsdale,  fibroid  of  ut.,  673 

Grisolle,  gangrene  after  abscess,  493 

Gueniotj  fibroid  of  ut.  and  diagn.,  666;  in- 
version ut. ,  628 

Gueneau  de  Mussy,  pruritus  vulva3  and  gouty 
diath.,  251,  760 

Guerin,  subcutan.  incision  into  ovarian  cyst, 
335  ;  pelvic  cellulitis,  480  ;  injection  of  ut.. 
466  ;  colpitis,  740 

Gull,  ovarian  cyst  containing  air  and  fluid, 
300 

GUntz.,  e.  u.  gest.,  391 

Gusserow,  sarcoma,  713 

Guyon,  obliterated  os  ext.,  44  ;  ruga?  of  cerv. 
ut.,  43  ;  size  of  ut.,  44;  experim.  on  inject- 
ing ut.,  466  ;  inversion  of  ut. ,  623 


Habit,  sloughing  of  cancerous  ut.,  718 
Hall,  M.,  prolaps.  ut.,  oper.  for,  571 


•74 


INDEX     OF    AUTHORITIES. 


Haller,  cicatrices  on  ov  and  corpora  lutea, 
27  ;  source  of  menstr.  blood,  150  ;  pelv. 
hasmat. ,  520 

Halley,  foetus  retained  in  ut.,  388 
Hamilton,  prolaps.  ut.,  oper.  for,  571 

Hannover,  epithelioma,  710  ;  cane,  ut.,  715 

Hare,  elongation  of  ut.,  578 

Harley,  G. ,  air  expelled  from  ut.,  82 

Harley,  John,  polypu.s  ut.,  686 

Harris,  infantile  men.=tr.,  153 

Harvey,  uterine  sound,  122 

Haselberg,  V.,  death  from  injecting  ut.,  465  ; 
dilat.  of  fundus  vag.,  743 

Hassall  [see  Index  of  Figure.^!) 

Haussinan,  dysmenorrhoeal  membr.,  227 

Haydon,  tubal  gest.,  380 

Heath,  colloid  cancer  of  ov.,  273  ;  fibroid  of 
ut.,  673 

Hebra,  ut.  dis.  and  skin  dis.,  440 

Hecker,  ov.  gest.,  376;  interstitial  gest.,  389 

Heckford,  cancer  in  child,  703 

Hegar.  hydrorrhoea  gravidarum,  84  ;  pelv. 
hsemat.,  504 

Helie,  muscular  fibres  of  ut.,  49  ;  pelv. 
hsemat.,  523 

Heming,  jjrolaps.  ut.,  oper.  for,  572 

Hennig,  tubal  and  ut.  mucous  membr. 
during  gest.,  371  ;  exper.  on  injecting  ut., 
466  ;  aspirator  tube,  478 

Henle,  F.  t.,  31;  follicles  of  vag.,  60,  439; 
Graafian  follicles,  22 

Herbiniaux,  "tumeur  vivace,"  710 

Hericourt,  De,  air  pessary  for  anteversion  of 
nt.,  587 

Heschl,  fungosities  of  ut.,  686 

Hermann,  death  from  inject,  ut.,  464 

Heurtaux,  contents  of  pelv.  hsemat.,  511 

Hev?er,  atresia  of  vag.,  Ac,  186 

Hewitt,  G.,  anteversion  pessary,  587 

Heyfelder,  e.  u.  gest.,  391 

Hicks,  B.,  puncturing  by  rect.  for  occlusion 
of  ut.,  191;  e.  u.  gest.,  382;  tubal  gest., 
380 

Hildebrandt,  fibroid  of  ut.,  668 

Hirschfield,  nerves  of  ut.,  55 

His,  lymphatics  of  ov.,  26  ;  medullary  struc- 
ture of,  22 

Hodgkin,  complex  ov.  cysts,  281 

Hoening,  sound  passing  through  F.  t.,  142  ; 
fibroid  tum.  of  ut.,  640 

Hoffman,  amenor.,  169 

Hohl,  anteversion  of  ut,,  581 

Hooper,  dropsy  of  F.  t, ,  356 

Huchard,  menstr.  metritis,  229 

Huguier,  amputation  of  hypertrophied  cerv. 
ut.,  110;  arteries  of  ut.,  54;  bursting  of 
ov.  cysts,  298  ;  cysts  on  ext.  surface  of  ut. , 
319;  ut.  sound,  122,  123  ;  violaceous  color. 
of  vag.  in  pregnancy,  364  ;  vulvo- vaginal 
gland,  64  ;  ulc.  of  ut.,  438;  pelv.  haemat., 
607;  hypertr.  of  cerv.  ut.,  544;  prolaps. 
ut.,  oper.  for,  573  ;  inversio  ut. ,  636  ;  cyst. 
tum.  of  vag.,  752;  vulvitis,  755;  "  ender- 
moptosis, "  761 

Hulke,  oper.  for  lacerated  perineum,  751  ; 
sarcoma,  714 

Hunter,  John,  imperfection  of  testes,  115; 
inversion  of  ut.,  619 

Hunter,  Wm.,  suggests  ovariotomy,  336  ;  in- 
version of  ut.,  624 

Hutchinson,  adhesion  of  ov.  cyst,  344  ;  ova- 
riotomy clamp,  341 ;   ov.  turn.,  two  classes, 


324;  amaurosis  in  lact.,  413;  gastrotomy 
in  e.  u.  gest.,  384;  recurrent  fibroid  of  ut., 
651  ;  effects  of,  658  ;   tubercle  of  ut.,  696 


Ingleby,  e.  u.  gestation,  391 
Ireland,  prolaps.  ut.,  oper.  for,  571 


Jarjavay,  "corpus  spongiosum"  of  ov.,  25 
Jobert,    nerves  of  ut.,    55  ;    endoscope,    122  ; 

actual  cautery  in  metritis,  450  ;  vesico-vag. 

fist.,  749 
Joerg,  e.  u.  gestation,  391 
Johns,  Robert,  blistering  cerv.  ut. ,  452 
Jones,  Sydney,  ovariotomy  forceps,  341 
Jones,  Wharton,  transmigration  of  ovum,  367 
Jungel,  on  hsemat.,  510 


Keith,  on  ovariotomy,  338  ;  sulphuric  ether 
in,  339,  347 

Keller,  gastrotomy  in  e.  u.  gest.,  382 

Kennedy,  B.,  placental  souffle  in  e.  u.  gest., 
364  ;  nitric  acid  in  ut.  medicat.,  470 

Kidd,  axial  rotation  in  ov.  tum.,  296;  nitric 
acid  in  ut.  medicat,  470  ;  pressure  of  fib- 
roid on  sacral  plexus,  660:  fibroid  of  ut., 
655,  668,  670 

Kiwisch,  abdominal  gest.,  376,  381  ;  absence 
of  decidua  in  tub.  gest.,  371  ;  div.  ov.  tum. 
into  two  classes,  324  ;  drawing  off  liq.  am- 
nii  through  vag.,  372;  F.  t.  bursting  from 
carcinoma,  350;  inflam.  of  follicles  of  ov. , 
261;  trocar  for  tapping  ov.  cysts,  328; 
mortality  from  tapping,  330  ;  ov.  gest.,  376  ; 
parenchymatous  ovaritis,  262  ;  peritonitis, 
182  ;  rupture  of  tubal  sac,  362  ;  tubercu- 
losis in  ov  ,  268;  tum.  (enchondromatous) 
of  ov.,  276;  tubo-ovarian  cysts.  284;  ut. 
sound,  123;  gastrotomy  in  e.  u.  gest.,  381, 
385  ;  polypus  ut.,  686  ;  fibrinous  polypi,  686 

Klemm,  on  injecting  ut. ,  466 

Klob,  application  of  one  tube  to  opposite  ov. , 
368;  obliterated  os  ext.,  177;  intra-ut. 
transmigration,  369  ;  vag.  forming  sac  in 
obstruction  at  vulva,  183  ;  fibroid  of  ut., 
640 

Kobelt,  bulb  of  vag.,  60  ;  parovarium,  28 

Koeberle,  diagn.  of  fibro-cystic  tum.  of  uterus, 
313  ;  mortality  in  ovariot.,  346  ;  e.  u.  gest., 
379  to  386;  gastrotomy  for  fibroid  of  ut. , 
674,  675 

Kohlrausch,  dermoid  ov.  cysts,  290 

Kolliker,  Fallopian  tube,  32  ;  vaginal  glands, 
439 

Kussraaul,  absence  of  ut. ,  177  ;  application 
of  tube  to  opposite  ov.,  368;  gest.  in  one 
horn  of  ut.,  391 

Kiister,  Dr.,  effects  of  fibroid  tum.  of  ut.,  658 


Laaser,  bifid  vag.,  110 

Laborderie,  pelv.  heemat.,  504 

Laboulbene,   pelv.    hasmat.,  from  scarlatina, 

523 
Lair,  uterine  sound,  123 
Lancereaux,  cystic  endometritis,  473  ;  fibroid 

of  ut.,  654;  forms  of  malignant  dis.  of  ut., 

715 
Lane,  J.  R.,  vesico-uterine  fist.,  749;  lacerat. 

of  perineum,  750 


INDEX    OF    AUTHOEITIES. 


775 


Langenbeck,  cane,  and  amput.  of  prolaps. 
ut.,  560  ;  inversion  of  ut. ,  620 

Lapeyronie,  excision  of  eerv.  in  cane.  ut. ,  728 

Larcher,  rupt.  of  ut.,  from  fibroid  turn.,  390  ; 
effects  of  fibroid  of  ut.,  659  ;  polypus  ut., 
679 

Laugier,  pelv.  hsemat.,  504,  519 

Lauvariot,  excision  of  cerv.  ut.  in  eanc,  728 

Laycock,  excessive  pigment,  162 

Lazzari,  excision  of  cerv.  in  cane,  ut.,  728 

Lazzati,  inversion  of  ut.,  618,  629 

Leak,  epidemicity  of  leucor.,  74 

Lebert,  dermoid  cysts  of  ov.,  290;  fibroid  of 
ut,  641;  cane,   of,  702,  710 

Ledran,  incision  of  ov.  cyst,  334 

Lee,  C.  H.,  fibro-cystic  turn,  of  ut.,  313;  in- 
version of,  624 

Lee,  Robt. ,  nerves  of  ut. ,  55  ;  cause  of  menstr. , 
146  ;  strangulation  of  polypi,  689 

Leger,  muciparous  follicles  of  vestibule,  64 

Legrand,  injection  of  iodine  into  ov.  cysts,  333 

Leith,  puberty  in  Bombay,  152 

Lente,  intra-ut.  medic,  467 

Leroy,  occlusion  of  bifid  ut. ,  178 

Lesouef,  e.  u.  gest.,  365,  372,  374  ;  rupture  of 
tubal  sac,  374  ;  bsemor.  in.,  364  ,  electricity 
in,  372 

Letheby,  changes  in  ov.  at  puberty,  27  ;  micr. 
char,  of  menstr.  blood,  151  ;  retained  men- 
strual fluid,  182 

Leuret,  mania  with  menstr.,  246 

Levrat,  gastrotomy  in  e.  u.  gest.,  382,  385  ; 
hypert.  of  cerv.  ut.,  542  ;  anteversion  of 
ut.,  580  ;  instrument  for  polypus  ut.,  689  ; 
"  tumeur  vivace,"  710 

Liebman,  fibroid  of  ut. ,  653  ;  cane.,  716 

Liebreich,  R.,  retinal  hsemor.  from  suppressed 
menses,  155 

Lisfranc,  revulsion,  426  ;  inversio  ut.,  623  ; 
fibroid,  667  ;  amput.  of  polypus,  691 ;  cane, 
ut.,  721,  729 

Little,  Dr.,  and  Little,  L.  S.,  saline  injections 
in  cholera,  97 

Lize,  retained  menstrual  fluid,  182,  418 

Lobstein,  nerves  of  ut.,  55 

Locock,  excision  of  polypi,  691 

Longet,  nerves  of  ut. ,  56 

Louis,  cessation  of  menses  and  tuberculosis, 
243 

Lowenhardt,  diagn.  of  ovaritis,  263;  inject- 
ing iodine  into  ov.  cysts,  333 

Lud,  nerves  of  ut.,  55 

Liiders,  pessary  found  in  rectum,  566 

Lunier,  cretinism  postpones  puberty,  171 

Luschka,  transmigr.  of  ov.,  368  ;  ov.  cysts, 
281  ;  glandula  coccygea,  768 


Macdonald,  A.,  latent  gonorrhoea,  740 

Macintosh,  dilatation  of  os,  206  ;  sterility  and 
contracted  os  ut.,  205 

Macleod,  vaginal  glands,  465 

Madge,  pelv.  hsemat.,  504,  511 

Magrath,  fibroids  of  ut.  and  e.  u.  gest.,  367 

Malgaigne,  hair  in  polyp,  ut. ,  686;  induces 
adhesion  between  ov.  oyst  and  abdom.  wall, 
335;  use  of  utero-sacral  lig.,  36;  pelv. 
hsemat.,  504;  inversio  ut,,  627  ;  vascular 
polyp,  ut.,  686;  "Champignons  cance- 
reux,''  728 

Malpighi,  muscular  fibres  of  ut.^  49 


Mandl,  menstr.  blood,  149  ;  vag.  glands,  439  ; 
chlorate  of  pot.  in  membr.  dysmenor.,  233 

Marcha],  perimetric  inflam.,  483 

Marotte,  epilepsy  with  menstr.,  246 

Martin,  C.  A.,  muciparous  follicles  of  vesti- 
bule, 64 

Martin,  Ch.,  inverted  ut.,  reduced  by  cold 
irrigation,  630 

Martin,  Prof.  E.,  arrest  of  tubal  gest.  by 
punct.  through  vag.,  372  ;  perforation  of 
ut.  by  sound,  142  ;  anteflexion  of,  583  ; 
retroflexion,  602  ;  inversion,  620 ;  dilata- 
tion of  fundus  vag.,  743 

Mason,  vicarious  menstr.,  155 

Maurer,  e.  u.  transmigration,  368 

May,  rupture  of  ovarian  tum.,  299 

Mayer,  A.,  on  Zwanck's  pessary,  567 

Mayer,  C,  vascular  pol.  ut. ,  686;  cane,  ut., 
710;  sarcoma,  713;  foil,  excor.  of  cerv., 
436;  pyrolign.  acid,  450;  bipartite  ut. , 
395  ;  amput.  of  cerv.,  574 

Maygrier,  use  of  round  ligament,  35 

McClintock,  pelv.  abscess,  490  ;  hsemat.,  504- 
507  ;  diagn.,  &g.,  of  fibroid  of  ut.,  663,  664, 
667,  669  ;  cysts  on  ext.  surface  of  ut.,  320  ; 
air  in  ut.,  82  ;  on  pessaries,  563  ;  inversion 
ut.,  620,  633  ;  peritonitis  from  fibroid  tum. 
of  ut.,  660  ;  fibrin-polypus.  686  ;  death 
from  polypus  ut.,  689  ;  cysts  of  vag.,  752  ; 
cane,  of,  753  ;  tum.  of  vulva,  762  ;  syphil. 
hypertr.  of  nymphse,  763  ;  lupus  of  vulva, 
764 

McDiarmid,  influence  of  cold  on  menstr.,  152 

McDowell,  first  ovariotomy,  336 

Meadows,  cystiform  dilat.  of  both  F  t.,  355  ; 
opening  periton.  in  amput.  of  cerv.  ut.,  576  . 

Meissner,  vascular  pol.  ut.,  686 

Moir,  retroflexion  of  ut.,  614 

Monro,  muscular  fibres  of  ut.,  49 

Montgomery,  membranous  dysmenor.,  226  ; 
vascular  pol.  ut.,  686  ;  diagn.  of  eanc.  ut., 
721 

Moore,  dermoid  cyst  of  ovary,  292 

Morgagni,  epidemicity  of  leucor.,  74;  tubo- 
ov.  cysts,  284;  ut.  mucous  membr.,  50; 
hypertr.  eerv.  ut.,  542 

Mtiller,  vibratile  current  accounting  for  ex- 
tra-uterine gestation,  368 

Miiller,  H.,  retained  menstrual  fluid,  182; 
cysto-sarcoma  of  ovary,  283 

Murchison,  cyst  of  ovary  opening  into  reet., 
300 

Murray,  G.,  pelv.  peritonitis,  489;  galvanic 
pessary,  4 1 6 

Murray,  John,  closure  of  vagina,  182 


Naegele,  hydrorrhoea  gravidarum,  84 ;  os  ut. 

sealed  by  false  membr.,  177 
Negrier,  ovaries  act  alternately,  223  ;  epilepsy 

under   ov.    irritation,    246 ;    periodicity   of 

menstr.,  146  ;  changes  in  ov.  at  puberty,  27  ; 

dysmenor.,  218  ;  early  cessation  of  menstr., 

153  ;  gest,  on  insanity,  247  ;  iliac  pain,  220  ; 

ov.   function,    152;   ov.   temperament,   219; 

gest.  and  ovulation,  158;  softening  of  brain 

and  menstr. ,  245;  "  ovarie"  for  "hysterie, " 

222  ;  vesieulite,  261 
Nelaton.    ovulation   cause    of  haemat.,    519  ; 

retro-uterine  haemat.,   504,  531  ;  fibroid  of 

ut.,  669 
Newman,  spontan.  cure  of  cane,  ut.,  718- 


776 


IXDEX    OF    AUTHORITIES. 


Nissen,  instrument  for  polypus,  689 
Noeggerath,    taxis  in  inversion  of  ut.,    631  ; 

latent  gonorrhoea,  740 
Nonat,  pelv.,  hsemat.,  504,  607;  intra-uterine 

fungosities,  fi86 
Nott,  coccygodynia,  7fi8 
Nunn,  elongation  of  ut.,  578 


Obre,  case  of  menor.,  92 

Ogle,  fibrous  turn,  of  ut.,  687 

Oldham,  no  deciduain  tube  in  tubal  gest.,  371  ; 
fluid  in  F.  t. ,  357  ;  membranous  dysmenor., 
226  ;  puncture  by  rect.  in  occlusion  of  ut., 
191;  enlargement  of  urethra  in,  178;  ster- 
ility from  contracted  os  ut.,  205  ;  transmi- 
gration of  ovum,  367 ;  channelled  polypus 
ut.,  683 

Ollenroth,  tapping  and  keeping  open  ovarian 
cyst,  334 

Olshausen,  anteut.  hsemat.,  508  ;  peritoneal 
hfemat.,   509,  510 

Osiander,  excision  of  cancerous  cerv.  ut.,  728 


Pagello,  pepsin  in  cane,  734 

Paget,    dermoid    cysts,   292  ;    ov.  cysts,   277  ; 

fibroid  turn,  of  ut  ,  651  ;  scirrhous  ut. ,  714 
Fallen,  retention  of  menstrual  fluid,  183 
Paris,  pelv.  cellulitis,  480 
Parker,  fatal  obstruction  of  rect.  by  enlarged 

ovary,  297 
Parkinson,  fibroid  of  ut  ,  673 
Payne,  gangrene  in  prolaps.  ut.,  558 
Pean,  ablation  of  ut.,  673,  674 
Peaslee,  distension  of  F.  t.  with  ov.  cyst,  356  ; 

ov.  turn,  diagn.,  305  ;  treatment  of,  325  ;  ut. 

headache,   443  ;  pessary  for  retroflexion  of 

ut.,  614 
Perkins,  absence  of  ut.,  177 
Petit,  M.  A.,  inversion  of  ut.,  624 
Pfetfinger,  e.  u.  gest.,  391 
Piorry,  iliac  pain  due  to  ov.,  220 
Playfair,  pelv.,  abscess  cause  of  haemat.,  177; 

anteversion  pessary,  587 
Poppel,   no   decidua   serot.    formed  in   F.  t., 

371  ;  interstitial  gest.,  388 
Pott,  P.,  removal  of  ovaries,  147 
Pouchet,     changes    in    ov.    at   puberty,     27  ; 

phases  of  menstr.,  148 
Powell,  ciciitricial  closure  of  vag.,  184 
Power,  periodicity  of  menstr. ,   146 
Prieger,  fibroid  of  ut..  667 
Priestley,    intermenstrual     dysmenor.,    218: 

sound  for  dilating  cervix,  207  ;  perforation 

in  cane,  ut.,  721 
Prost,  pelv.  haemat.,  504 
Puech,     atresia   of    vulva,    176,    182  ;    pelv. 

hsemat.,  504 
Puzos,  hydrorrhoea  gravidarum,  84 


Quekett,  vascular  growth  of  meatus  ur.,  764 


Raciborski,  ovulation  and  menstr.,  147; 
changes  in  ov.  at  puberty,  27  ;  periodicity 
of  menstr..  147;  mucous  membr.  of  dysme- 
nor. and  decidua  of  pregnancy,  229  ;  milk 
in  menstr.,  159 

Radford,  galvanism  as  an  oxytocic,   171 


Rainey,  arteries  of  ut.,  54;  round  ligament  of 
ut.  and  uses,  34,  11 1 

Ramsbotham,  dermoid  cyst  in  Douglas's  space, 
291  ;  fibro-muscular  tum.  of  ut.  and  ov., 
274 ;  punct.  of  imperforate  hymen,  190 ; 
e.  u.  gest,  388,  391;  inversio  ut.,  623; 
ligature  of  inverted  ut. ,  634 

Ramskill,  fatal  hsemor.  from  polypus  ut.,  681 

Rasch,  Ad.,  vaginal  movements,  82 

Raulin,  epidemicity  of  leucor.,  74 

Recamier,  adhesion  by  caustics  between  ov. 
cyst  and  abdom.  wall,  335  ;  curette,  475  ; 
perimetric  haemat.,  504;  fungosities  in  en- 
dometritis, 475  ;  excision  of  cancerous  cerv. 
ut.,  729 

Reid,  John,  vascular  growth  of  meatus  ur., 
765 

Richard,  P.  t.,  30,  32,  110;  ov.  cysts  dis- 
charging through  F.  t.,  302  ;  tubo-ov.  cysts, 
284 

Richardson,  spray  apparatus,  105 

Richet,  axis  of  ut.,  38;  broad  ligament,  34; 
nerves  of,  55  ;  size  of,  44  ;  utero-sacral  lig., 
36  ;  pelv.  haemat.,  504,  524  ;  fibroid  of  ut. , 
676  ;  vascular  growth  of  meatus  ur.,  766 

Rieord,   oophoritis,  261 

Rigby,  neuralgic  dysmenor.  and  rheumatic 
diathesis,  194  ;  oophoritis  and  membranous 
dysmenor,  232  ;  revulsives,  427  ;  fibroid  of 
ut.,  666,  667  ;  prolaps.  of  ov.,  253;  ov.  dropsy 
from  oophoritis,  280 

Ringland,  nitric  acid  in  ut.  medic,  470 

Ritchie,  fibro-cystic  tum.  of  ov.  276  ;  ova  in 
simple  ov.  cysts,  277  ;  ovulation  without 
menstr.  disch.,  148 

Roederer,  condition  of  ov.  in  menstr.,  147; 
hydiorrhoea  gravidarum,  84 

Robert,  pelv.  haemat.,  507;  intractable  ulc.  of 
ut.,  714 

Roberton,  early  menstr.  and  pregnancy,  154  ; 
prolaps.  ut  ,  552 

Robin,  F.  t.,  32;  leptothrix  buccalis,  72; 
fibroid  tum.  of  ut.,  641  ;  intractable  ulc.  of 
ut.,  715 

Rokitansky,  absence  of  ov.,  252  ;  anomalies 
in  corpus  luteum,  255  ;  atrophy  and  twist- 
ing of  F.  t.  by  ov.  turn.,  296  ;  bifid  ut.  and 
ulcer,  of  septum  from  retained  menstr. 
fluid,  178;  brain  matter  in  ov.  cysts,  290  ; 
cancer  of  ov.,  270  ;  cause  of  separation  of 
ov.  from  ut.,  254;  condition  of  mucous 
membr.  of  ut.,  229  ;  constriction  of  intes- 
tines by  rotation  of  dermoid  ov.  tum.,  297  ; 
degenerations  of  corpus  luteum,  255;  dupli- 
cation of  corpus  luteum,  255  ;  oophoritis, 
259  ;  ova  in  simple  ov.  cysts,  277  ;  remains 
of  Wolffian  duet,  350  ;  F.  t.  represented  by 
a  rounded  stump  attached  to  horn  of  ut., 
350  ;  senile  atrophy,  producing  obliteration 
of  OS,  178;  transmigration  of  ov.,  368; 
tuberculosis  of  F.  i;.,  350;  of  ov.,  268;  en- 
larged uterine  glands,  428,  431  ;  abnormal 
gest.,  388,  391  ;  atresia,  401  ;  pelv.  hjemat., 
613  ;  lateral  position  of  ut.,  577  ;  anteflex. 
of  ut.,  583,  590;  retroversion  of  ut.,  596; 
retroflex.  of,  602;  inversion  of.  618;  poly 
pus  ut  ,  686;  tubercle  of,  697  ;  villous  can- 
cer, 710;  scirrhus,  714;  hypertr.  of  clit- 
oris, 761  ;  hermaphroditism,  761 

Romberg,  iliac  pain  due  to  ov.,  220 

Roper,  G.,  rupture  of  F.  t.,  in  tubal  gest., 
370  ;  calculus  in  prolaps.  ut.,  538 


INDEX    OF    AUTHORITIES. 


777 


Roseniniiller,  abnormal  gest.,  392 
Rouget,  corpus  spongiosum  of  ut.,  54  ;  medul- 
lary struct,  of  ov.,  22  ;  ov.  bulb,  26  ;  broad 
ligament,  34;  v;ig.,  muscular  walls  of,  60 
llouth,   dilatation  of  urethra,   178;    endome- 
tritis, 460  ;  scarificator,  433  ;  sponge-tent  in 
heemor.,  475;    bromine  in  cane,   ut.,    733; 
pepsin  in,  734 
Roux,  excision  of  cane.  eerv.  ut.,  730 
Rupin,  twin  pregn.  outside  ut.,  373 
Ruysch,    hydror.    gravidarum,    84 ;     binding 
down  of  fimbriee,  and  so  sterility,  110;  pelv. 
hsemat. ,  520;  cancer  of  prolapsed  ut.,  560 


Sacchi,  induces  adhesion  between  ov.  cyst 
and  abdominal  walls,  335 

Saint  Morrissey,  De,  ov.  gest.,  375      ^ 

Savage,  fibroid  of  ut  ,  670 

Saxinger,  pelv.  hsemat.,  504 

Scanzoni,  vaginal  tapping,  328 ;  amput.  of 
hypertr.  cerv.,  110;  aloetie  enema,  169; 
bursting  of  distended  hymen,  182  ;  dis.  ov.. 
110;  classif.  of  ov.  tum.,  324;  dropsy  of 
Graafian  ves.  from  oophoritis,  280  ;  fibrous 
tum.  of  ov. ,  274;  leueor.  and  vaginitis, 
77;  effect  of  dysmenor.  on  ut.,  195;  effect 
of  menstr.  on  ov.  turn.,  303  ;  incision  of 
cerv.,  212  ;  effect  of  ovulation  on  hyperemia 
of  genitals,  160;  origin  of  salpingitis,  353; 
post-m.  appearances  of  oophoritis,  260,  266  ; 
gest.  not  arresting  ovulation,  158  ;  iodic  in- 
jections in  ov.  cysts,  333;  sterility,  113; 
vaginismus,  106;  abnormal  gest.,  391  ;  en- 
dometritis, 463  ;  diagn.  of  gest.,  381  ;  in- 
jecting ut.,  466;  intra-ut.  med.,  450;  me- 
tritis, 435;  pelv.  hajmat.,  504  ;  haemat. 
from  measles,  523;  revulsion,  427  ;  varicose 
ule.  of  eerv.,  438;  fibroid  of  ut.,  653,  661, 
668  ;  placental  polypus,  686 

Scherer,  contents  of  ov.  cysts,  287 

Schoenbein,  aloetie  enemata,    169 

Schroeder,  perforation  of  ut.  by  sound,  142  ; 
pelv.  heemat.,  525;  invers.  of  ut  .  630 

Schultze,  e.  u.  transmigr.,  369  ;  oophoritis, 
263;  position  of  ov.  in  oophoritis,  263 

Schutz,  epithelial  cancroid,  710 

Sehutzenberger,  iliac  pain  due  to  ov,,  220 

Sedgwick,  decay  of  fibroid  of  ut.,  653 

Seller,  hernia  of  ov.,  254 

Seaton,  retro-ut.  hasmat.,  514 

Seyfert,  pelv.  hsemat.,  504 

Siebold,  amputation  of  polypi,  691 

Simon,  G.,  bifid  ut.,  atresia  of  left  vag.,  179  ; 
closure  of  vag.,  distended  ut.,  182  ;  post, 
culporrhaphy,  574 

Simon,  John,  on  inflammation,  430 

Simpson,  Alex  ,  anteversion  pessary,  587  ;  in- 
version of  ut.,  636  ;  fibroid  of,  667 

Simpson,  Sir  J.,  chloroform  in  phantom  turn., 
238;  coceygodj'iiia,  lOli,  4+2,  767;  diagn. 
of  ov.  dropsy,  ;^57  ;  dry  cupping  ut.  in  ame- 
nor. ,  170  ;  fertility  of  peerage,  109  ;  fibroid 
turn,  of  F.  t. ,  351;  incision  of  cerv.,  211  ; 
dysmenor.  from  obstruction  at  os  int.,  206  ; 
sterility  from,  205  ;  involution  of  ut.,  409  ; 
inject,  of  chloroform  into  vag.,  197  ;  polyp- 
tome,  691  ;  easts  in  membr.  dysmenor.,  226  ; 
adhesive  vaginitis,  188,  190;  tapping,  336; 
neuralgia,  167:  galvanic  pessary,  167;  ut. 
sound,  123  ;  retroflex.  of  ut. ,  612  ;  inversion 
of,  627 


Sims,  Marion,  curette,  475  ;  flexion  of  ut.  by 
fibroid  turn.,  215  ;   danger  of  dilating  cerv. 
by  sponge  tents,  208  ;  incision  of  cerv.,  214; 
ovariotomy  in  gest.,   348;   speculum,  432; 
vaginismus,  103  ;  ut.  hook,  476  ;  prolaps.  ut., 
oper.  for,  673  ;   opening  periton.  in  amput. 
of  cerv.   ut.,    576;    inversio  ut.,    630;    liga- 
ture of  inverted  ut.,  634  ;  fibroid  of  ut.,  669  ; 
vesieo-vag.  fist.,  748 
Sireday,  pelv.  hsemat.,  519 
Skene,  chloride  of  zinc  in  cane,  ut.,  733 
Skinner,  incision  of  cerv.,  214;   inversion,  629 
Skoldberg,  cautery  clamp,  343 
Smith,  early  menstr.  and  pregnancy,  154 
Smith,  P.,  retroversion  of  ut.,  596 
Smith,  Tyler,  endoscope,  122  ;  Fallopian  cathe- 
terization, 359  ;  genesial  cycle,  158  ;  super- 
foetation  in  F.  t.,  380  ;  transmigration,  369  ; 
leueor.,  76,  78;  inversion  of  ut.,  630 
Soltau,  W.  F.,  rupt.  of  ov.  cyst  into  periton., 

298 
Southam,  mortality  from  tapping  ov.  cysts,  331 
Spiegelberg,  tubal  gest.  going  on  t )  term,  362, 
374  ;  echinococcus  of  kidney  and  ov.  cysts, 
315;    suppuration    and    perforation   of   ov. 
cysts,  301 
Statfeld,  fungosities  of  ut.,  686 
Stolz,  hypertr.  of  eerv.  ut.,  544 
Storer,  gastrotomy  for  ut.  fibroid,  673 
Sutton,  hypertr.  of  vag.  walls,  183  ;  injecting 
the  ut.,  464 


Tait,  L.,  perfor.  of  ut.  by  sound,  142  ;  axial 
rot.  of  ov.  turn.,  296  :  gastrotomy  for  e.  u. 
gest.,  383;  inversion  of  ut.,  630 

Tansini,  pepsin  in  cane.,  734 

Tardieu,  crim.  intercourse,  78  ;  hemor.  from 
periton.,  525 

Tarral,  excision  of  cane.  cerv.  ut.,  728 

Tavignot,  tapping  ov.  cysts  by  rect.,  328 

Teallier,  diagn.  of  inflam.  and  cane.  ut. ,  721 

Tessier,  disch.  of  mucous  membr.  of  vag. 
from  perehl.  of  iron,  230,  466 

Thomas,  stillicidium  mens,  from  contracted 
vag.,  188;  ut.  sound,  123;  intra-ut.  medic., 
468 ;  anteversion  pessary,  587  ;  reduction 
of  inverted  ut.,  632  ;  incision  of  eerv.  for 
inversion  of  ut. ,  637  ;  malignant  dis.  of  ov. , 
273 

Thorman,  abdominal  gest.,  rupture  of  cyst, 
377 

Thudichum,  leucin  in  ov.  cyst.  288 

Tiedemann,  nerves  of  ut.,  56  ;  abnormal  gest., 
391 

Tilt,  unconsciousness  from  pressure  in  ov. 
region,  221  ;  vaginismus,  106  ;  endometritis, 
460  ;   pelv.  hismat.,  504 

Tracy,  prolaps.  ut. ,  oper.  for,  575 

Trelat,  urethral  pad,  749 

Trousseau,  blood  from  mucous  membr.,  154  ; 
induces  adhesion  between  ov.  cyst  and  ab- 
dom.  walls,  335  ;  iodine  and  saffron  in 
araenor.,  168  ;  pelv.  haimat.,  504,  619  ;  peri- 
met,  inflam.,  486;  turpentine  in  membran- 
ous dysmenor,  233 

Tuckwell,  occlusion  of  vulva,  183;  intra- 
perit.  hemor.,  508  ;  perimetric  hemor.,  604  ; 
rupture  of  tubal  vein,  524 

Tulpius,  excision  of  eanc.  cerv.  ut  ,  728 


778 


INDEX    OF    AUTHOEITIES. 


Turner,  Prof.,  separat.  and  transplant,  of  ov., 
296  ;  malform.  of  gen.  organs,  393  ;  fibroid 
of  ut.,  648 


TJcelli,  ov.  gest.  .375 
Uhde,  ov.  gest.,  376 
Ulrioh,  foetus  retained  in  ut.,  388  ;  rupture  of 

ov.  cyst  into  bladder,  300 
Urdy,  on  ablation  of  ut.,  673 
Uterhart,   occlusion  of  vag.  by  cicatrix   and 

dilated  urethra,  178 


Valleix,   uterine  sound,    123  j    retroflexion  of 

ut.,  612 
Valletta,  amput.  of  inverted  ut.,  634 
Veit,  diagn.  of  oophoritis,  264 
Velpeau,  e.   u.   gest.,   370,   375;    gastrotomy, 

381,  385;   use  of  round  ligament,  35,  111  ; 

inversio    ut.,    626  ;    fibroid,  671 ;    polypus, 

681  ;    on  amputation  for  cancerous    cervix 

ut.,  728 
Verneuil,  axis  of  ut.,  38  ;   pelv.  hsemat.,  507  ; 

relapse  of  vesieo-vag.  fist.,  749 
Vigues,  pelv.  heemat.,  504 
Virchow,   absence    of  decidua  from  F.  t.  in 

tubal  gest.,  371  ;   brain   matter  and   muse. 

fibre  in  ov.  cysts,  291  ;   menstrual  decidua, 

227 ;    detachment    of   muc.   membr.   of  ut. 

during  menstr. ,  149  ;   mucous  membr.,  87  ; 

struct,  of  ov.  in  chronic    oophoritis,   266  ; 

perimetritis   and    parametritis,   482  ;    pelv. 

hsemat.,   525;    hypertr.  of  cerv.   ut.,   544; 

prolaps.  ut.,  557;    anteflexion  of  ut.,  583  ; 

cane,    ut.,    710;    sarcoma,    713;    abnormal 

gest.,  392 
Vogel,  fibroid  turn,  of  ut.,  641 
Voisin,  pelv.  hsemat.,  504,  507,  525 


Wade,  W.,  pelv.  hsemat.,  530 


Wagner,  hsematoma  of  F.  t.,  355 

Waldeyer,  erection  of  ov.,  22 

Walter,  nerves  of  ut. ,  56 

Walter,  P.  U.,  ovarian  gest.,  375 

Ward,  0.,  rupture  of  ovarian  turn.,  304 

Webb,  ova  in  simple  ovarian  cyst,  277 

Wedl,  uterine  dis. ,  from  malnutrition,  441; 
urethral  caruncle,  764 

Weit,  sarcoma,  713 

Wells,  Spencer,  passim  in  Chapter  on  Diseases 
of  Ovary  ;  pelv.  hsemat.,  524  ;  fibroid  of  ut., 
666 

West,  conception  without  menstr.,  153  ;  neu- 
ralgic and  congestive  dysmenor. ,  194;  pru- 
ritus vulvffi  and  diabetes,  251  ;  metritis 
hemorrhagica,  434;  pelv.  hsemat.,  504; 
kidney  in  prolaps.  ut. ,  538;  pessaries.  563; 
on  oper.  for  prolaps.  ut.,  566  ;  inversion  ut. , 
623,  6.?0  ;  fibroid,  668  ;  cane,  ut  ,  706  ;  can- 
cer, 711;  syphil.  of  vulva,  763 

Whitehead,  Dr.,  vaginal  mucus,  73,  149  ;  con- 
ception without  menstr.,  163;  suppression 
of  menstr.,  171;  endometritis,  250;  intra- 
ut.  medic,  466;   prolaps.  ut.,  552 

Whitehead,  Walter,  atrophy  of  ut.,  402,  418  ; 
on  oper.  for  prolaps.  ut.,  576 

Wilks,  formation  of  cysts  in  ovary,  28 1  ;  kinds 
of  ovarian  turn.,  276 

Williams,  Wynn,  bromine  in  cane,  733 

Willigk,  A.,  ovarian  gestation,  375 

Willis,  on  arresting  convulsions,  221 

Willoughby.  tubercle  of  ut.,  697 

Wilson,  J.  Gr.,  early  menstruation  and  preg- 
nancy, 1  54 

Wiltshire,  sloughing  of  ut.  in  cane,  730 

Wiltshire  and  Watson,  ovariotomy  when  cyst 
had  ruptured,  348 

Wood,  ovarian  cyst  containing  fat,  291  ;  pro- 
lapse and  hernia,  563 

Woodman,  inversion  of  ut.,  624;  fungosities 
of  ut.,  686 

Woodson,  inversion  of  ut.,  619 


INDEX   OF   SUBJECTS. 


Abdomen,  dilatation   of  superficial  vessels  of, 
295 

enlargement  and  subsidence  of,  150 

enlargement   of,  175,  183,  204,  223,   236, 
237,  292,  296,  321 

examination   of,  by   palpation,  &o.,  139, 
305,  307,  314 

scar-like  cracks  on.  306 
Abdominal  belts,  and  use  of,  238 

distension,  75,  345,  346 

sbock  and  collapse,  266,   362,   376,  492, 
508 
Abortion,  68,  79,   92,  95,  112.   203,   204,  225, 
261,  304,  316,  348,  349,  365,  472 

hemorrhage  from,  355,  364 

retrograde    hemorrhage    from,    93  ;    and 
pelvic  hsematocele,  516 
Abscess,  310,  317 

encysted  peritoneal,  319 

of  breast,  416 

perimetric,  319,  490,  531 

pelvic,  83,  490,  493,  502 
Acetic  acid  in  cancer,  733 
Acne,  244 

Acupuncture  in  diagnosis,  665 
Ague,  172 
Air,  expelled  from  vagina  and  uterus,  82 

sucking  of,  into  ovarian  cyst,  329 
Alcoholic  stimulants,  224,"  240 
Amenorrhoea,  67,  163 

apparent,  176 

causes  of,  165.  171  flocal,  165),  172 

course,  duration,  consequence,  and  diag- 
nosis of,  173 

from  retention,  175 

local  exploration  of,  68 

presumptive,  68 

primitive,  163 

prophylaxy  of,  173 

secondary,  or  accidental,  163,  171 

treatment  of,  174 
Amputation    of  hypertrophied   cervix    uteri, 
111,  573 

of  cancerous  vaginal-portion,  731 

of  inverted  uterus,  631 
Anteversiou   and  anteflexion    of  uterus 

"  Uterus  '') 
Aneemia,  69,  75,  165,  168,  300,  362 
Anaesthesia,  197 
Anasarca,  306,  337 
Aorta,  imperfectly  developed,  165 

pressure  upon,  294 
Aphasia.  239 
Apoplexy,  235,  240,  241 
Arbor  vitse,  43,  50 
Ascarides,  77  {vide  "  Leucorrhoea  ") 


Ascites,  273,  303,  310,  318,  320,  323 
with  ovarian  cystic  disease,  319 

Asphyxia,  295,  296 

Aspirator-trocar,  314,  319,  371,  372,  665 

Asthma,  244 

Atelectasis  of  new-born  infants,  295 

Atresia,  175  {vide  "  Uterus,"  "  Vagina,"  and 
"Vulva"') 
congenital  or  acquired,  176 
of  OS  externum,  77,  184,  189 

Auscultation,  309 

Autogenetic  puerperal  fever,  485 


Ballottement,  306 
Barren,  definition  of,  108 
Bartholini's  gland,  64 

inflammation  of,  106,  557,  755 
Bichloride  of  methylene,  339 
Binder,  use  of,  85,  331 

Bladder,    distension    of,    267,    310,    324   {vide 
also  "  Urine,  Retention  of") 

dragged  down  in  prolapsus  uteri,  537 

emptying  of,  357 

fistulous  opening  of,  70,  745 

irritability  of,  100,  175 

pressure  upon,  69,  351 

uterus  and  tumor  pressing  upon,  296 
Blennorrhcea,  103,  263,  345,  353 
Blood  {vide  ''  Ovarian  Tumors  and  Effusions," 
"  Hemorrhage  ") 

alteration  in  state  of,  243 
in  cancer,  718 

collection  of,  in  Fallopian  tube,  352,  355 

effused  into  peritoneum,  299,  329,  347 
ovarian  cyst,  229 

effusion  of,  356,  377 

behind  uterus,  67,  138 

hyperfibrination  of,  347 

watery  state  of,  164,  165 
Bone  in  dermoid  cyst  of  ovary,  290 
Bowels,  constipation  of,  75,  76,  100,  169,  235, 
253,  357 

irritability  of,  176 

spasm  of,  235 
Brain,  degenerative,  inflammatory,  and  con- 
gestive disease  of,  244 
Breasts,  atrophy  of,  153 

changes  of,  in  pregnancy.  305 

enlargement  of,  237 

influenced  by  ovarian  tumor,  304 

pain  and  duration  of,  150,  236 

turgidity  of,  160,  204 

tumor  of,  244,  245 
Bright's  disease,  303,  306,  337 


780 


INDEX    OF    SUBJECTS. 


Broad  ligament  (vide  n\so  "Uterus") 

cysts  of.  277.  320,  323,  327,  332,  350,  359, 
360  (tapping  of,  361) 

disease  of,  261 

encysted  abscess  of,  364 

hemorrhage  into,  374 

inflammatioa  of,  360 

obstruction    of    bloodvessels    and    varix, 
524;   lymphatics,  360 
Bromine,  117 

in  cancer,  733 
Bronchitis,  chronic,  244 
Bronchocele.  243 
Bruit-de-diable,  165,  168 
Bulb  of  vagina,  60,  63  (vide  also  "Vagina") 


Cachexia,  273 

Calculus  vesicae  in  prolapsus  uteri,  538 
Canal  of  Nuck,  35.  62 

Cancer  (fjV«  also  "Uterus,"  "Ovary,"  "Va- 
gina," and  "Vulva"),  91,  92,  100, 
101,  103,  136,  320,  338 

hemorrhage  from,  89,  722 

odor,  722 

of  breast,  160,  270 

of  vulva,  251,  764 

of  ovary,  270  (vide  "Ovary") 

of  uterus,    177,  219,  238,  239,    251,    270, 
272,  312,  701 
"  cancer-mushroom, "  722 
Canula,  334 

Carbolic  acid,  117,  294,  343,  344 
Carunculse  rayrtiformes,  59 

inflammatioa  of,  104,  105 
Catamenia  (vide  "Menstruation") 
Catheter,  116,   324,326,   33  i,   333,   334,    338, 

343 
Cauterizing  iron,  344 
Cautery,  339,  346 

galvanic,  540,  541 

clamp.  339,  343 
Caesarian  section,  383 
Cervix  uteri  (vide  "  Uterus") 

abrasion  and  hypertrophy  of,  92 

amputation  of.  177,  540 

conical,  205 

cystic  tumor  of,  473 

dil.atation  of,  by  incision,  209 

engorgement  of,  92 

impevfeciion  of,  176 

iniiammution  of,  92,  138,  203 

means  and  usefulness  of  dilating,  96 

plugging  of,  211,  214 

spa.«modic  contraction  of,  184 

turgidity  of.  233 

ulceration  of  (and  os),  112,  158,  159,  436 
"Change  of  life,"  234 
Chest-walls,  fixing  of,  295 
Childbirth,  influence   of,  on  nervous  system, 

246 
Chloasma,   uterine,  441 
Chloro-ansemi.i,  or  chlorosis,  163,  165,  281 

distinction  from  leukfemia,  165 
Chloroform  and  inhaler,  117 

inhalation  of,  224,  327,  339 
Cholesterin  crystals,  287,  2S9 
Chorea,  243 
Chorion.  369 

hydatidiform  degeneration  of,  85 

villi  of.  375 

villi  of,  in  membrane,  from  uterus,  231 


Chorion,  villi,  simulation  of,  by  ducts  of  utric- 
ular glands,  231 
Chorionic  sac  attached  to  ovary,  376 
Chromic  acid,  117 
Clamp,  339,  341,  342 
Climacteric  [vide  also  "Menopause"),  106 

early,  153 

in  man,  234 
Clitoris,  anatomy  of,  60,  63 

disease  of,  63,  761 
Clots,  retained,  92 
Coccygeal  gland,  768 
Coccygodynia.  106,  442,  766 
Colic,  77,  375 
Colica  scortorum,  356,  366 
Colitis,  103 
Collapse,   266,    295,   329,  333,  345,  347,  362, 

375  (vide  "Abdominal,"  also  "Shock") 
Colpitis,  103  (vide  "Vaginitis'') 
Oolporrhaphy.  674 
Conception,  148 
Concussion  or  shock,  244 
Condy's  fluid,  294,   344 

Convulsions,  221,  223,  239,  240,  245,  265,  374 
Copraeuiia,  604,  719 
Corpora  lutea,  367,  368,  369 

absence  of,  from  follicle,  264 

cystic  degeneration  of,  255 

degenerations  of,  to  a  fibrous  tumor,  257 
to  carcinoma.  256 

dendritic  protrusion  of,  255 

description  of,  24,  25 

duplications  of,  255 

evolution  of,  25 

false,  25 

origin  of,  25,  28 
Corpus  spongiosum  of  uterus,  54 
Counter-irritation,  258 
Cystocele,  vaginal,  742 

Cysts    (vide    "Ovary,"    "  Broad  Ligament, " 
"Vagina,"  "Vulva") 

between  amnion  and  chorion,  84 

layers  of  chorion,  84 

extra  ovarian,  310,  360 

of  chorion,  85 
Cystitis,  293,  297 


Decidua,  113,  227 

tubal  gestations,  370,  371 
extravasations  into,  113 
hypertrophy  of,   84 
Delirium,  195,  197,  204,  239 
Dementia,  197,  244 
Deodorants  and  disinfectants,  737 
Developments,    imperfect   and    disproportion- 
ate, 106 
Diabetes,  244,  251,  758 
Diagnosis,  67 

of  disea.<e  of  pelvic  organs,  132 

of  pelvic    peritonitis,   from  retro-uterine 

hsematocele,  87 
of  ovarian  dropsy,  ascites,  and  pregnancy, 
305 
Diathesis,  75 

gouty   and   rheumatic,  75,  112,  194,  250, 

758 
syphilitic,  75,  112,  245 
tubercular,  75,  243,  246 
Diet,  75,  169,  241,  343 

Digestive  organs,    disorder  of,  235,    236,  240, 
719 


INDEX     OF    SUBJECTS. 


781 


Dilating  materials,  206 
Discharges,  albuminous,  69 

aqueous,  69,  8>S 

significance  of,  86 

containing  epithelium-cells,  70 

fleshy,  69 

indications  of,  69 

leucorrhoeal    {vide    "  Leucorrhoea"),    68, 
69,  72 

membranous,  69,  225 

mucous,  69,  70 

purulent,  69,  87 

sanguineous,  68,  69,  70,  88 
Discus  proligerus,  23 
Displacements  (vide  "Uterus,"  &c.) 
Dodging  time  of  life,  234 
Dorsal  decubitus,  83,  144 
Douglas's  sac  or  pouch,  exudation  in,  265 

fluid  in,  345 
Drainage-tube,  339 
Dropsy,  319 

Dyschezia.    100,  182,  253.  262 
Dysentery,  103,  244,  329 

Dysmenorrhoea,    77,    79.    113,    163,    175,    184, 
212,  244,  257,  262,  266,  280 

sign  of  ovarian  dropsy,  218 

causes  of,  68,  192,  199 

congestive,  193,  198 

treatment  of,  199,  206,  210 

definition  and  kinds  of,  193 

difference  between  membrane  of,  and  de- 
cidua  of  pregnancy,  229 

endometritic,  461 

from  tubal  obstruction,  193,  224 

from  mechanical  anomalies  of  uterus,  193 

from    obstructed    excretion   and   causes, 
201,  224,  262,  352 

seat  of  stricture,  206 

symptoms  of,  204 

from  ovarian  disorder,  193,  217,  219 

inflammatory,  225 

membranace"a,  200,  225,  227,  228 

more  common  in  married  life,  231 

symptoms,  231 

treatment  of,  232 

neuralgic  or  sympathetic,  193,  196 

uterine,  219 
Dysootocia,  217,  266 
Dyspareunia,  68,  107,  110,  203,   232,  253,  257 

causes  of,  68 

acquired,  102 
congenital.  102,  104 

cure  of,  103,  105 

significance  of,  102 
Dyspepsia,  75 
Dysuria,  106,  293,  316,  357 


Eclampsia,  240 

Ectopic  gestation    (vide  "Extra  Uterine  Ges- 
tation") 

menstruation,  154 
Ecraseur,  chain  and  wire,  339 
Eczema  of  vulva,  250,  758 
Effusions  of  blood  (vide  "  Blood,")  92 
Electricity,  in  tubal  gestation,  371 
Embolism,  347,  720 
Embryo,  destruction  of,  227,  374 
Emmenagogue?,  170 

Emotion,    exaggerated,    104,    236,    237,   245, 
260,  263 

influence  of,  166 


Emotion,  influence  of,  on  menstruation,  171, 

172 
Emphysema,  244 
Endocervicitis,  229.  460 

Endometritis,     chronic,    205,    245,    250,    453 
(vide  also  "  Uterus") 

cystic,  473.  474,  478 
Endoscope,  116,  122 
Enuresis,  297 

Epilepsy,  197,  235,  240,  243,  246 
Epistaxis,  vicarious,  &c.,  154,  235,  238 
Ergot  and  ergotin,  170,  667 
Erysipelas,  250 
Erythema  nodosum,  155,  164 
Ether,  339 
Examination  by  bladder,  138 

by  speculum.  136 

of  patients,  67 

of    secretions,    discharges   or  substances 
expelled,  136 

rectum, 312,  313 

vagina,  238 
Excretion,  70,  163,  176 

mechanical  obstruction  of,  198 
Exploratory  incision,  314,  324 
Extra-uterine  gestation  (vide  "  Gestation") 
Eye,  instrument  of  observation,  116 

retinal     hemorrhage,     from     suppressed 
menses,  155 

vicarious  ecchymosis  of,  155 


Facies  ovariana,  307 
Fallopian  tubes,  19,  29,  110 
abnormalities  of,  213 
absence  of,  110,  252,  350 
carcinoma  of,  350 
■    catarrh  of,  and  causes,  353,  354 
catheterization  of,  359 
closure  of  uterine  and  fimbrial  ends,  356, 

359 
congestion  of,  150,  174 
cysts  of,  350,  355,  360,  365 
dangers    of   distension,   perforation,    &e., 

353    354   359 
dilatation  of,  181,  183,  191,  352,  354,  356 
diseases  of,  260 

treatment,  358 
dragging  on,  253 

dropsy  of,  322,  327,  353,  356,  364 
contents  of  tube  in  dropsy,  105 
dropsy  associated    with   general    dropsy, 
356 
dependent  on  other  causes,  357 
symptoms,    diagnosis  and  treatment 
of,  357,  359 
elongation  and  causes  of.  352 
fimbriae  of,  30 
supernumerary,  350 
gestation  in,  59 
hypertrophy  of,  352 
impervious,  224,  367,  369 
inflammatory  adhesions  of,  366 
inflammation    and   suppuration    of,    and 

causes,  353,  354,  355 
laceration  of,  and  cause,  181,  190 
ligament  of,  30 
ligature  of,  373 
obliteration  of  vessels  leading  to  atrophy 

of  uterus,  361 
obstruction  of,  by  polypi,  367 
occlusion  of,  93,  110 


782 


INDEX    OF    SUBJECTS. 


Fallopian  tubes,  phlebolithes  and  phlebitis  of 
vessels,  361 

puncture  of  tubal  sac,  373 

retention  in,  355 

rupture  of,  182,  353,   354,  362,  370,  373 
374 

signs  of  distension,  353 

tubercle  in,  269,  351 

tumor  of.  350,  351,  361 
Fffices,  accumulations  of;  263,  310,  322 
in  csecum,  263 

stoppage  of,  365 
Fecal    abscess,  communicating   with  ovarian 

cyst,  301 
Fecundity,  112 
Fibrinogen,  287 
Fistula  (vide  "Vagina'') 
Flatulence,  75 
Flooding  {vide  "Menorrhagia''  and  "  Metror 

rhagia") 
Fluctuation,  double,  307 

fallacy  of  308 

in  fibro-cystic  tumor  of  uterus,  314 

in  ovarian  tumor,  307,  313 
Fluxion,  423,  425 
Foetus,  movements  of,  237 

retardation  of  growth,  373 

retention  of,  380 
Follicles  of  vulva,  64 

Follicular  inflammation  of  cervix  uteri,  436 
Forceps,  339 

artery,  torsion,  and  bull-dog,  339 

Wells's  long  screw  forceps,  342 
Fossa  navicularis,  62 
Fourchette,  62,  105 

fissure  at,  1  04 
Fungosities,  intra-uterine,  475,  686,  716 


Gallstones,  242 

Galvanic  cautery,  294,  541,  731 
Ganglionic  system,  irritation  of,  347 
Gangrene  from  cancer,  704 

in  prolapsus,  557 
Gastrotomy,  374,  375,  673 
Genital  canal,  occlusion  of,  70,  163 

stenosis  and  atresia  of  180 
Germinal  vesicle  and  spot,  24 
Gestation,  107,  112,  234 
abdominal,  370,  376 
cervical,  369,  370 
ectopic,   370 

extra  uterine,  92.  93,  254,  286,  293,  363, 
365,  366 
influence  of,  on  uterus,  370 
symptoms,  dangers,  &c.,  of,  363,  364, 

365 
treatment  of.  371 
in  Douglas's  pouch,  365 
in  one  horn  of  uterus,  390 
interstitial,  or  intramural,  362,  375,  387 
ovarian,  375,  376 

tubal.  322,    .327,   353,  357,  362,  365,  366, 
376,  377 
danger  and  termination  of,  363,  364 
diagnosis  of,  372 
physical  signs  of,  365 
treatment  of,  371 
tubo-ovarian,  362,  369,  375,  376 
Gonorrhrjea,  71,    72,    78,   354,   356,    488,   740, 
759 
"latent,"  740 


Gout,  244,  250 
Graafian  vesicles,  22,  24 

bursting  of,  into  adherent  tubes,  285 

changes  in   at   menstrual   epoch,  27,  147 

contents  of,  287 

dehiscence  of,  148,  149 

destruction  of,  109 

disease  or  bursting  of,  262,  264 

dropsy  of,  280 

enlargement  of,  287 

existence  of,  in  foetus,  27 

fibrous  degeneration  of,  256 

inflammation  of  follicles,  261 

inflammation  of,  266 

morbidly  dilated,  277,  279 
Green-sickness  [vide  "  Chlorosis") 
Gynaecologist's  bag  and  contents,  115 


Hfematocele,  83,  138,174,  243,  310,  315,  316, 
374 
cataclysmic,  506 
catamenial,  519,  523 
dingnosis  and  treatment  of,  530 
pelvic,  perimetric,  retro-uterine,  503,  528 
ante-uterine,  508 
rupture  of,  529 
Hsematemesis,  hereditary,  155 

menstrual,  154 
Hajmatometra,  191 
Hsematuria,  92 
Haemoptysis,  155 
Hsemorrhoids,  104,  155,  235 
Hsemostatics,  application  of,  95 
Hemorrhages,  76,  89,  239,  329,  349,  363,  364, 
365 
abdominal,  93 
active  and  passive,  89,  96 
after-treatment  of,  97 
associated  with  other  symptoms,  90 
causes  of,  with  structural  alteration,  92 

without  structural  alteration,  91 
climacteric  and  senile,  91 
death  from,  347,  373 
from  blood  disease,  91,  243 
cancer,  722 

congested  cervical  canal,  159 
decidua  vera.  158 
emotion  and  shock,  94 
excess  of  coitus,  91 
heart,  liver,  or  lung  disease,  91 
ovarian  or  mammary  excitement,  91 
polypus,  680 

suppressed  action  of  skin,  91 
suppression  elsewhere,  91 
fibroids,  660 

varicose  ulcer  (vicarious),  155 
in  endometritis,  474,  523,  524 

pelvic,  506 
during  lactation  and  gestation,  91 
of  placenta  prsevia  and  Fallopian  gesta- 
tion contrasted,  370 
poured  out  internally,  93,  346,  370 
significance  of,  88 
treatment  of,  93 
Hemorrhagic  diathesis,  155 
Hand,  in  diagnosis,   116 
exploration  by,  136 
Headache,  158,    164,  168,  174,   176,  204,  217, 

223,  235,  239,  346 
Heart,  disease  of,  with  amenorrhoea,  ^3 


INDEX    OF    SUBJECTS. 


783 


Heart,  deposit  of  fibrinous  eoagula  in  disease 
of  and  menstruation,  244 

disease  of  and  cancer  of  ovary,  272 

disease  of  and  ovarian  tumor  and  ascites, 
310,  317 

fiitty  and  feeble,  91 

feeble  and  irritable,  164 

hypertrophy  of,  dilated,  240 

imperfectly  developed,  165 

pressure  upon,  295,  720 
Hectic  fever,  85,  175,  182,  293,  303,  334 
Heterogenetic  puerperal  fever,  486 
Hiccup,  347 

Higginson'S  vaginal  syringe,  118,  131 
Hip-bath,  value  of  warm,  169 
Hodge's  pessary,  103,  117,  187,  188,  189,  268, 

567,  598 
Hull's  utero-abdominal  support,  570 
Hydrometra,  180,  295 
Hydrops  tubse,  352 
Hysterical  mania,  247,  248 

pains,  166 

temperament,  257 
Hydrorrhoea,  catarrhal,  84 

gravidarum,  83 

puerperal  form  and  causes,  84 
Hydrometra,  454 
Hydronephrosis,  704,  719 
Hymen,  59,  64 

atresia  of,  176 

description  and  structure  of,  59 

remains  of,  105 

unyielding   and    imperforate,    181,    189, 
190 
HypersRmia,  92,  251,  427 
HyperEBsthesia,   69,  102,   103,   104,  194,   198, 

219,  220,  245 
Hyperlactation,  75 
Hypochondriac  stitch,  101 
Hypochondriasis,  236 
Hysteralgia,  99 

Hysteria,  98,    104,    162,    195,   210,    211,    218, 
220,  244,  249.  257 

causes  of,  222 

depending  on  ovarian  disturbance,  221 
uterine  irritation,  100 


Idiocy  and  menstruation,  244 
Ileus,  death  from,  by  ovarian  tumor,  297 
Illumination  for  examination,  143 
Impregnation,  110,  112,  267 

ovarian,  376 
Incision  of  cervix,  293 

followed  by  peritonitis,  489 

mode    of  operation,    and   structures    di- 
vided, 215 

necessary  instruments  for,  215 

results  and  appreciation  of,  211 
Indian  hemp,  oxytocic,  170 
Inflammation,  general  theory  of,  420 

and  vide  individual  organs  by  name 
Injections,  uterine,  95,  464 
Insanity,  246,  247 
Instruments,  diagnostic,  116 

for  special  purposes,  67 

importance  of,  in  diseases  of  women,  67 

therapeutical,  116 

use  of,  136 
Intertrigo,  250 

Intra-uterine,  caustic  holder  and  carrier,  117, 
128 


Intra-uterine,  injecting  apparatus,  117,  130 

injections,  260,  263.   464 

medication,  464.  468 

transmigration  of  ovum,  369 
Involution  {vide  "Uterus'")  407 
Iodide  of  mercury  ointment,  117 
Iodine,  117,  373 

in  urine,    perspiration,  and  breath   after 
injecting  cyst,  333 

paint,  268 

tincture  of,  injected,  322,  323,  325 
Iron,  mode  of  action,  167,  170 
Irritative  fever,  319,  329  {vide  "Hectic") 


Kidneys,  cystic  disease  of,  315 

diseases  of,  265,  273,  310,  318 
in  cancer,  719 
in  prolapsus  uteri,  539,  557 

echinococcus  of,  315 

enlargement  of,  310,  315 

floating,  315 

hyperasmia  of,  303 

imperfect  action  of,  238 

obliteration  of,  by  tumor,  297 

pressure  upon,  242 

secreting  power  increased  after  tapping, 
332 
Kreatin  and  kreatinin,  in  ovarian  cysts,  289 
Kreuznach,  waters  of,  113,  472 
Kiichenmeister's  metrotome  scissors,  125 


Labia  majora,  62 

adhesion  of,  176 

excessive  development  of,  110 

sebaceous  follicles  of,  64 

varicosity  of  vessels,  92 

minora,  62  {vide  "Nymphae") 
adhesion  of,  176 
Labor,  316 

constitutional  effect  of,  407 

effect  of,  on  uterus,  418 

induction  of,  premature,  349 
Lactation.  107,  234,  412,  413 
Leeches,    use   of,    92,  169,  224,  225,  233,  241, 

246,  253,  258,  268,  346,  432 
Leptothrix  buccalis,  72 
Leueocythsemia.  91 
Leucorrhoea,  203,  230,  235,  247,  253,  267 

causes  and  significance  of,  73,  74,  75,  78, 
164 

diagnosis  of,  79 

menstrual,  74 

occult,  79 

of  children,  77,  78,  739 

physiological,  74 

results  or  effects,  78 

strumous  and  syphilitic,  80 

uterine,  vaginal,   and  vulvar,  74,  76,  77, 
■   78 
Leukaemia,  165 
Leucin  in  ovarian  cyst,  289 
Levator  ani,  58 

Lever  pessary  ii;ide  "  Hodge's") 
Ligatures,  341,  342,  344,  345 
Liquor  amnii,  84 

drawing  off  in  tubal  gestation,  372,  373 
Lithiasis,  242 
Lithopsedion,   380 
Liver,  acute  yellow  atrophy  of,  243,  523 

atrophy  of,  91 


784 


INDEX    OF    SUBJECTS. 


Liver,  cancer  of,  270 

diseases  of,  173,  244,  310.  318 

enlargement  of,  310,  315 

extravasations  of  blood  in,  265 

hydatid  of,  316 

imperfect  action  of,  238,  241,  242 
Lumbar  colic,  246 
Lumbar   and   pelvic  glands,    tubercular  and 

other  diseases  of,  323,  324 
Lung  disease,  91,  173,  174,  310 

condition  of,  337 

pressure  upon,  295 

tubercle  of,  269 
Lupus  of  vulva,  764 

Lymphatic  vessels  and  glands,  26,  703,  704, 
720 


Malarious  affections,  243 

Malformation,  68 

Malignant  disease  {vide  "  Cancer  ") 

of  caput  coli,  273 
Malignant  jaundice,  243 
Mania,  195,  203,  244,  246 
Measles,  243,  523 
Meatus  urinarius.  63 

disease  of,  92 

vascular  excrescence  of,  104,  261,  765 
Melancholy,  244,  246 
Membranes,  rupture  of,  84 
Menopause,  234 

disorders  and  treatment  of,  240 
Menorrhagia.  89.  92,  111,  149,  163,  164,  200, 
203,  204,  219,  228,  238,  247,   253,  267, 
30-4,  354 

common  in  hot  climates,  150 

local  causes  of,  68,  108,  112 
Menstruation,  absence  of,  110 

abrupt  suppression,  172 

age,  when  beginning,  and  how  influenced, 
161 

characters  of  discharge,  148,  149,  257 
retained  blood,  182 

climacteric  irregularity,  234 

compared  with  that  of  mammals,  27 

critical,  243 

dependent  on  quality  of  blood,  166 

described,  27,  90,  160,  161 

difficult,  leading  to  effusion  of  blood,  518, 
521 

during  lactation,  159 

early  cessation,  causes  of,  153 

easy  condition  for,  206 

exaggerations  of,  91 

first  sign  and  first  period,  148 

hemorrhagic  tendency  hereditary,  91 

imperfect,  164,  217.  218 

increased  by  difficult  ovulation,  219 

indications  of,  149,  150 

influenced  by  surrounding  organs,  68 

influence  of  ovulation   and  menstruation 
in  evoking  morbid  influences,  242 

irregularity  of,  89,  149 

local  conditions  and  impediments  of,  160, 
161 

not  coinciding  with  ovulation,  222 

not  index  of  state  of  ovary.  248 

obstruction   of,  producing   morbid  influ- 
ence on  breasts,  244 

occult.  67,  163,  176 
signs  of,  176 

partial  retention  of,  199 


Menstruation,  peculiarity  of  blood,  149 
period  of  disappearance,  162 
periodicity,  dependence  on,  146,  151 
quantity  of  blood  discharged,  150 
relation  of,  to  ovarian  disease,  242 
retention  of,  175,  184,  199,  352 
safety-valve  and  depurating  channel,  238 
similarity   between   advent   and   climac- 
teric cessation,  150 
source  of,  160 
suppressed,  225,  236,  237,  260,  365 

results  of,  67 
suspended,  and  causes,  158,  165,  171,  242, 

264,  266,  316,  353,   364 
vicarious  or  ectopic,  154 
white,  153 
Menstrual  fluid,  characters  of,  149 

changes  produced  by  retention  in  uterus, 
200 
Mensuration  (of  abdomen),  307 
Mental  aberration,  245 

distress.  257 
Metalbumen,  287 

Metritis   {vide    also    ''Inflammation   of   Ute- 
rus"),  142,  226,  262,  264,  366 
course  of,  439 
chronic.  229,  267,  434 
curability,  445 
cystic,  453 
menstrual,  65,  229 
Metrorrhagia,  89.  96,  205,  224,  245,  313,  461 

definition  of,  89 
Metrotome,   117,  125 

description  of,  209,  215 
objections  to  double-bladed,  209,  210 
scissors,  117,  126,  215 
Milk,    alteration    in,    by    menstruation    and 
emotion,  159 
suspension  of,  496 
Mole,  fleshy,  vesicular,  375 
Mons  veneris,  61 
Morsus  diaboli,  376 
Mucous  membrane  of  uterus  differs  from  other 

mucous  membranes,  60 
Mucus,  72,  352 

albuminoid,  coagulated  by  injection,  re- 
sembling membrane,  230 
Mucin,  289 

Muciparous  follicles,  64 
Myoma  {vide  "Uterus,  polypus  of") 
Myxorna,  715 


Nabothian  glands  enlarged,  276,  453 
Natural  labor,  110 
Nelaton's  forceps,  340 
Nerves  of  uterus,  in  pregnancy,  65 
Nervous  derangement,  69,  222,  223,  224,  235, 
236 

excitement.  343 

irritability,  104,  248,  256,  349 
Neuralgia,  69,  243,  245,  249 

due  to  uterine  disease,  99 

treatment  of,  166 
Nonnengeriiusch,  165 
Nurse  and  nur.'sing,  338 
Nymphs9,  62,  762 


Obesity,  237 

Occipital  headache,  101 


INDEX    OF    SUBJECTS. 


785 


(Edema,  general,  164 

of  legs,  295,  303,  321,  337 
Ointments,  353 
Omentum  (and  intestines),  344 

enlargement  of,  310,  316 
Oophoralgia,  221,  256,  258 
Oophoritis,    26,    99,  171.  218,   222,   225,  257, 
258,  259,  260,  261,  285,  488 

appearances  of  ovary  affected,  260 

causes  of,  260 

chronic,  266 

course  of,  261 

diagnosis  and  symptoms,  262 

treatment  of,  268 
Ootocia,  217,  222 
Oozing  excrescence  of  labia,  86 
Opium,  use  of,  374 
Os  tinese  or  externum,  40,  41,  143,  144,  145 

atresia  of,  110,  176,  189,  250 

character  of,  137 

congenital  narrowing  and  results  of,  183, 
184,  195,  261 

difficulty  of  making  out,  180 

dilatation  of,  79 

fungous   granulation   and    ulceration  of, 
92,  177 

incision  of,  199,  250 

intense  red  ring  round,  250 

narrowing  of,    77,    79,   95,   96,   110,  199, 
200,  201,  202,  205,  213 

obstruction  of,  204 

opening  into  rectum  or  urethra,  1  78 

patency  of,  and  relative  position,  304 

sealing  of,  by  false  membrane,  177 

variations  of,  41,  46,  139 
Ostium  uterinum,  31 
Ova,  diseased,  110,  213 

in  abdominal  cavity,  376 

ripening  and  extrusion  of,  255 
Ovarian  temperament,  219 
Ovaries,  abnormal  conditions  of,  252 

abscess,    termination    and    treatment  of, 
265,  266,  268,  350 

absence  of,  20,  109,  147,  166,  252,  377 

action  of,  attracting  blood,  260 

activity  of,  during  pregnancy,  158 

adhesions  of,  to  side  of  pelvis,  bladder, 
rectum,  &o.,  254,  266,  310,  490 

adhesions  to  uterus,  264,  259,  267,  310 

adhesions   of,  with   Fallopian   tube,  114, 
254 

anomalies  of  relation,  254 

atrophy  of,   28,  110,  203,   205,  249,  252, 
255 
cause  of,  214 

atrophy,  gangrene,  and  strangulation  of, 
295 

attachment  of  foetus  to,  375 

congestion  of,  93,  103,  151,  160,  203,  258 

characters  and  significance  of,  223,  255, 
257 

cystic    disease    of   [vide   "  Ovarian    Tu- 
mors ") 

defective  development  of,  114,  147,  166 

deranged  function  of,  65 

description  of,  20,  25 

development  of,  26 

disease  of  parenchyma.  70.108,  110,  114, 
167,  173,  212,  213,  221,  262 

displacement  of,  and  causes,  252 

dropsy  of  {vide  "  Ovarian  Tumors") 

enlargement  of,  376 


Ovaries,  excessive  growth  of  follicles,  254 
involution  and  senility  of,  112 
excitation  of,  260 
exfoliation  of  epithelium,  229 
extirpation  of  (vide  "Ovariotomy''),  147 
extravasation  of  blood  into,  260 
fibroid  degeneration   of,  with   disappear- 
ance of  follicles,  267 
fibrous  disease  of,  271 
hernia  of,  252 

diagnosis,  254 
hyperemia  and  hypersesthesia  of,  262 
increased  bulk,    218,  252,  254,  257,  260, 

261,  285 
inflammation   of,    26,    99,    103,  171,  203, 

252,  263,  267 
inflammation  of  follicles  of,  261 
inflammatory  adhesions  of,  252 
involution  of,  219 
irritation  of,  99,  1U8,   113,   162,  203,  257 

(vide  "Oophoralgia"), 
ligaments  of,  20,  22 
lymphatics  of,  26 
malignant  diseases   of,    termination  and 

treatment,  266 
morbid  conditions  of,  194 
movement  with  uterus,  252,  253 
neuralgia  of  (vide  "  Oophoralgia  ") 
perforations  and  rupture  of,  266,  513 
prolapsus  of,  and  symptoms,  253 
proof  of  acting  alternately,  223 
pseudo-membranous  adhesions  of,  254 
results  of  pressure  when  tender,  220,  221 
scrofulous  disease  of,  351 
stimulation  of,  166 
structure  of,  20-24 
swelling  and  tenderness  of,  262 
tubercle  in,  350 
tumors  of — 

adhesions  of,  310,  320 

alteration  in  walls  of  uterus  by,  306, 

307 
benign  and  malignant,  309,  310,  321, 

322,  324 
cancer  of,  270 

medullary  and  gelatinous,  270, 

283 
hard,  271 
melanosis,  272 
colloid,  272,  273,  283 
cancerous  with  cavities,  324 
cystic  (various  kinds),  266,  270,  277, 

278,  316,   324,  357 
cystic  and  malignant,  167,  252 
adhesions  of,  with   bladder,  rectum, 

and  diaphragm,  300,  302,  303 
appearance  of,  340,  344 
atrophy  and  shrivelling  of,  296 
axial  twisting  of,  295,  296,  325,  349 
bleeding  from,  without  rupture,  300 

into  cyst,  295,  300 
cases  for   selection   of  interference, 

326 
communicating  with  ileum,  299 
complicated  with  pregnancy,  348 
conception  during  presence  of,  304 
contents  of,  287 

cutaneous,    proliferous,   or    dermoid 
cysts,  290 
bursting    of,    into  bladder    and 
rectum,  293,  300 


50 


786 


INDEX    OF    SUBJECTS. 


Ovaries,  tumors  of,  inflammation  and  ulcera- 
tion of,  &c.,  283,  293 
symptoms   and   treatment,    293, 

294 
cysts   discharging  througli  Fal- 
lopian tube,  302 
friable  and  rotten,  344 
multilocular,  276 

means  of  extracting,  344 
simple,   254,  272,  356,  358,  359 
simulating  tubal  gestation,  371 
small,  365 
dendritic,  cauliflower  growths  of,  301 
developed  from  wandering  ova,  286 
diagnosis  of,  in  early  life,  321 
distended  with  blood,  280 
excision  of  part  of  cyst,  335 
extirpation  of  {vide  "Ovariotomy") 
hemorrhage  into,  321,  322 
incision  of,  334 
keeping  open,  and  mode  of,  326,  327, 

328,  340 
mode  of  cure  after  tapping,  327,  328 
multiple,  and  how  formed,  280 
natural   course    and  termination  of, 

294 
perforation  and  causes  of,  301,  325 
presumption  of  being  free  from  ad- 
hesion, 320 
proliferous   or  compound,  with  col- 
loid contents,  281,  283,  324 
histology  of,  282 

proliferous,  &c.,  with  large  sarcoma- 
tous formations,  283 
rate  of  growth,  303 
rotation  of,  296 
rupture  of,  41,  93,  347,  349,  513 

containing  foetus,  375 
simple  or  barren,  277,  283 
spontaneous  rupture  of,  diuresis,  and 

recovery,  297,  298,  225 
suppuration  of,  301 
tapping,  310,  312,  320,  323,  326,  330, 
332.  337 
by  abdomen,  and  dangers,  329 
by  vagina,  326,  372 
cases   where    most   useful,   326, 

327 
objection  to,  328 
together  with  injection  of  iodic 
or  other  irritating  fluids,  325, 
327,  332 
tubo-ovarian  cysts,  256,  284 
how  formed,  280 
treatment  of,  medicinal,  325 
complicated,    with   pregnancy,   uter- 
ine fibroid,  and  ascites,  309,  312 
diagnosis  of,  305 

pregnancy  coexisting,  312 
enchondromatous,   276,  324 
fibrous  or  fibro-muscular,  274 
fibro-cystic,  276 
in  Douglas's  pouch,  308 
mistaken  for  pregnancy,  305 
solid.  273,  312,  324 
Ovariotomy,  310,  323,  329,  336,   339 
after-treatment,  343 
causes  of  death,  345 
dangers  of,  338 
instruments  required,  339 
precautions  before  operating,  337,  339 
Ovaritis  {vide  "Oophoritis") 


Oviduct  {vide  "Fallopian  tube") 

Ovula  Nabothi,  53,  453 

Ovulation,  107,  114,  234,  248,  260,  266 

diflScult,  109,  217,  218 

influence  of,  on  system,  158 

not  occurring,  109 

precocity  of,  152,  153 

significance  of,  148 
Ovum,  arrest  of,  110 

bursting  of,  in  tubal  gestation,  370 

description  of,  23.  24 

impregnated,    escaping   into    abdominal 
cavity,  374 

locality  of  impregnation  of,  369 

perishing  of,  267 
Oxytocics  {vide  "  Emmenagogues  ") 


Pain,  333,  345.  365 

abdominal,  85,  232 

bearing  down,  69,  232 
meaning  of,  100,  181 

colicky,  71  ^ 

crural,  69,  98 

iliac,  69,  203,  220 

in  cancer,  722,  724 

inguinal,  98 

lumbo-dorsal,  69,  98,  203,  219 

lumbo-sacral,  98,  100,  219 

ovarian   195,  196,  205,  257,  262,  267,  285 

pelvic,  69.  85,  98,  204,  219,  232 

rectal,  253 

shooting,  101,    346 

significance   of,    98,    195,    196,  201,  248, 
257,  266,  364,  371,  375 

stabbing,  101 

sudden,  intense,  362 

test  of,  depending  on  local  diseases,  101 

throbbing,  101 

uterine,  100 
Palpitation,  164 
Pampiniform  plexuses,  54 
Pancreas,  enlargement  of,  310,  315 
Paralbumen,  287 
Paramenia,  163 
Paraplegia,  244 
Parasites  of  vagina,  72 
Peculiarity  of  ovarian  veins,  54 
Pedicle  {vide  "Ovariotomy"),  341 
Pelvic  abscess,  83,  490 

aponeurosis,  58 

cellulitis,    87,    103,   211,   214,    310,    315, 
316,  357 

disordered  organs,  69 

distress,  316 

hsematoeele,  243,  503 
encysted,  374 
Pelvic  peritoneum,  encysted  abscess  of,  363, 
364 

inflammation,  487,  488 
adhesion  in,  494,  495 
cancerous,  500 

peritonitis,  112,  171,  184,  201,  203,  207, 
208,  211,  264,  310,  315 

projection,  221 

symptomatic  of  oophoria,  222 
Pepsin  in  cancer,  734 
Perchloride  of  iron,  117,  211,  214,  216,  230, 

339,  347 
Percussion,  309,  315 
Perimetritic  deposits,  200 
Perimetritis,  181,  201,   225,  298 


INDEX    OF    SUBJECTS. 


787 


Perimetric  inflammation,  479 

apart  from  pregnancy,  486 

causes  of,  486 

diagnosis  of,  497 
in  the  foetus,  486 

objective  characters,  501 

parametritis,  482 

perimetritis,  482 

pelvic  cellulitis,  480,  489 

rectal  touch  in,  499 
Perineum,  62,  105 

fissures  of,  104 

laceration  of,  111,  749 
operations  for,  760 

rupture  of,  82 
Peritonea]  dropsy  (encysted),  310,  317,  318 
Peritoneum,  340,  347 

closure  of,  by  sutures,  343 

division  of,  340 

exposed,  338 
Peritonitis,    74,  85,  103,   175,  181,    182,    190, 
195,  205,  208,   214,  254,  257,  260,  26], 
262,  266,  267,  285,  286,  300,  302,  316, 
319,  329,  333,  346,  489,  526 

meretricum,  488 

pelvic,  346,  347.  352,  353,  355,  356,  357, 
362,  363,  372.  373.  377,  484 

circumscribed,  67,  266 

encysted,  346 

general,  346 

ovarian,  262 

treatment  of,  346 
Peri-uterine  effusions,  138 
Pessaries,  92 

air  or  Gariel's,  117 

choice  and  mode  of  applying,  565 

cup-and-stem,  669 

description  of,  564 

for  reducing  inverted  uterus,  638 

Hodge's  ivide  "Hodge"),  667 

intra-uterine,  117 

medicinal,  117,  197,  253,  259 

Simpson's   intra-uterine,   galvanic,    117, 
201 

stem,  118 

Thomas's,  117 

use  of,  564 

vaginal,  105,  224,  448 

vulcanite,  intra-uterine,  117 

Wright's,  612 

Zwanck's,  666 
Phlegmasia  dolens,  321,  486 

and  hEematocele,  529 
from  cancer,  720 
Phthisis,  91,  173,  242,  243,  302,  303,  334,  337, 
351 

uteri,  697 
Physo-hydrometra,  85 
Physo-hsematometra,  182 
Pigment  in   menstruation,  162 

in  ovarian  cysts,  289 
Piles  {vide  "Haemorrhoids") 
Placenta,  50,  369 

detachment  of,  92 

hydatidiform,  92 

prsevia,  369 

retention  of,  84 
Plethora,  240 
Pneumonia,  244,  260 
Polyptome,  Simpson's,  691 

Aveling's,  691 


Polypus,  76,  81,  85,  86,  91,  94,  110,  126,  183, 

239  (vide  •'  Uterus,  polypus  of") 
Potassa  cum  calee,  117 
Poupart's  ligament,  352 
Pregnancy,  159,  311,  348,  349,  366 

false,  or  spurious,  235 

objective  signs  of,  305 

simulation   of,   176,   178,    183,    236   {vidi: 
"  Gestation  ") 
Prolapsus  {uide.  "Uterus") 
Prostration,  69,  249,  258 
Pruritus  of  vulva,  193,  768 
Pseudo-ovarian  cyst,  277 
Pseudocyesis,  235,  237.  314 
Pubico-vesical  plexuses,  63 
Pudic  veins,  64 
Puerperal,  fever,  485 

autogenetic,  486 

heterogenetic,  485 

mania,  246 

pelvic  peritonitis,  181,  226,  262,  479 

peritonitis,  26 
Purpura,  244 
Purulent  discharges,  indications   and  causes 

of.  87 
Pus,  77,  287,  345,  362 

escape  of,   due  to  pelvic  peritonitis  and 
suppurating  ovarian  cyst,  316 
Pysemic  fever,  175,  185,  214,  244 
Pyoid  bodies  of  Lebert,  289 


Quinine,  an  oxytocic,  170 


Recto-abdominal  pouch,  252,  304 

distension  of,  313 

by  cysts,  322 
Recto-vaginal  septum,  58 

fistula  {vide  "Rectum") 
Rectocele  vaginal,  742 
Rectum,  encroached  upon,  297,  327 

fissure,  104 
fistula  of,  70,  104,  747 

position  and  relations  of,  327 

pressure  upon,  69,  352 
Renal  dropsy,  367 
Rest,  343 

Rete  mirabile  of  ovary,  25,  54 
Retention  of  urine,  85 

cause  of,  67,  176,  183,  184,  211,  220,  321, 
365,  496,  626,  532 
Retro-uterine   hsematocele    {vide    "  Hsemato- 

cele  ") 
Retroflexion   and  retroversion  of  uterus,  495 

{vide  "  Uterus  ") 
Revulsives,  610 
Rheumatism,  244,  250 
Richardson's  styptic  colloid,  117 
Rutting  of  mammifera,  147 


Salines,  value  of,  168,  327 
Salpingitis  (vide  "Fallopian  Tube,  inflamma- 
tion of") 
Sarcoma  (vide  "Cancer") 
Scarifications  in  uterine  diseases,  117,  432 
Scarlatina,  78,  91,  172,  177,  243 
Schwalbach,  v^aters  of,  113 
Scrofula,  243 
Scurvy,  91 


788 


IJSTDEX    OF    SUBJECTS. 


Sebaceous  and  sudoriparous  glands  of  vulva 

and  labia  majora,  64,  73,  76,  77 
Secretion,  70,  144,  163,  176,  241,  248 

difficult,  218,  219 

mucus,  75,  180 

periodical,  248 
Secretory  apparatus  of  genitals,  64 
Sedatives,  197,  224,  233,  241,  327 
Semen  and  spermatozoa,  70,  79,  111 

arrest  of,  110,  213 
Senility,  disorders  of,  349 
Septicaemia,  85,  175,  181,  190,  206,  208,  319, 

347,  484 
Sexual  act,  106,  107 

awkward,  106,  108,  111 

danger  of,  106,  261 

feeling,  want  of,  173 

indulgence,  excessive,  260,  521,  525 

influence  of,  on  maturation  of  ova,  148 

organs,  imperfectly  developed,  166 

tolerance  of,  111 
Shock,  374  [vide  "Collapse") 
Sims's  speculum,  83 

dilator,  188,  189 

tenaculum  hook,  117,  125,  215 

vaginal  rest,  117 
Silver  wire  v.  silk,  117,  342,  747 
Skeleton  diagrams,  135 
Skin  affections  and  uterine  diseases,  250 
Small-pox,  77,  91,  177,  243,  523 
Smell,  sense  of,  135 

Sound  (uterine),  116,  136,  139,  199,  203,  206, 
211,  215,  216,  321,  326,  374,  499 

caution  respecting,  139,  142,  211 

flexible  whalebone,  116,  124 

mode  of  using,  140,  143 

perforation  of  uterus  by,  142 

use  and  description  of,  122,  146,  357 

use  of  interdicted,  364 
Speculum,  79,  94,  103,  116,  117,  135,  136,  215 

Barnes's,  131 

bath,  449 

Bennet's,  Dr.  Henry,  119 

Cusco's,  120 

Fergusson's,  119,  143,  188 

forceps,  116,  125,  144 

glass,  106 

Neugebauer's,  121,  215 

mode  of  introducing,  145 
modification  of  (Barnes's),  121 

Sims's,  83,  120 

mode  of  introducing,  144 

tubular,  118,  122 

mode  of  introducing,  143 

valvular,  118,  119,  122,  143,  145 
advantages  of,  118,  119 

Weiss's  self-retaining,  122 
Spermatozoa  in  peritoneum,  376 
Spinal  cord,  disease  of,  243 
Spinal  irritation,  98 
Spiritus  Mindereri,  168 
Spleen,  enlargement  of,  310,  315 
Sterility,  73,  102,  203,  212,  231,  233,  253,  267, 
359 

absolute  and  incurable,  congenital  and 
acquired,  relative  and  temporary,  109, 
112 

definition  of,  108 

in  man,  115 

of  prostitutes,  366 

significance  and  causes  of,  107 

treatment  of.  111 


Stethoscope,  116.  118,  305 
Stimulants,  use  of,  374 
Stillieidium  mensium,  188 
Strychnia,  action  of,  170,  373 
Styptics,  346 

Suppositories  opiate,  224,  253,  343 
Suppuration,  329 

Supra-renal  capsules,  disease  of,  172 
Sutures,  343,  344,  747 

Symptoms  and  subjective  signs  of  uterine  dis- 
ease, 66,  68,  69,  102,  115,  133,  193,  223, 
237,  263 

and  objective  signs  of  uterine  disease,  66, 
69,  115,  132,  193,  223 
Syncope,  104,  240,  246,  247,  333,  375 
Synovitis,  chronic,  245 
Syphilis,  92,  744,  762 

secondary  affections,  244 

taint  of,  232 
Syphilization,  373 
Syringe,  for  washing  out  vagina,  117 


T  bandage,  328 
Taetus  eruditus.  135 
Taxis,  254 

"forcible,"  631 
Temperature,  rise  of,  257,  303,  319 
Tenotomy  knife,  105 
Tents,  dangers  of,  208 

efiect  of,  on  cervix,  208 

laminaria,  116,  207,  250 

mode  of  introducing,  207 

sponge,  116,  207 
Tetanus,  347 
Thermometer,  118 

Thrombosis  of  veins,  303,  347,  720,  734 
Tonics,  233,  241 
Touch,  abdomino-vaginal,  136,  322 

bi-manual,  268 

education  of,  135 

mediate  (sound  in  utero),  312 

modes  of  application  and  importance  of, 
135 

recto-abdominal,  136,  263,  268 

recto-vaginal,  13& 

sense  of,  135 

simple  abdominal  palpation  and  percus- 
sion, 136 

simple  rectal,  136,  138,  268,  309 
vaginal,  136,  268,  309,  312 

urethro-rectal,  136 

uterine  (exploration  by  sound),  136 

utero-abdominal,  136 
Town  life,  75 

Trichomonas  vaginalis,  72 
Trocar  and  canula,  327,  332,  339,  345 
Tubal  catarrh  {vide  "  Fallopian  Tube  ") 

retention  {vide  "  Fallopian  Tube  ") 
Tube  for  carrying  solid  substances  into  uterus, 

117,  128 
Tubercle  of  abdominal  glands,  351 

of  lungs,  351 

(vide  "Uterus,"  "Ovaries,"  <fcc.) 
Tubercular  ulceration  of  uteri,  714 
Tuberculosis,  165 

Tumors,  110,  237,  [vide  "Ovaries,"  "Ute- 
rus," "Fallopian  Tube,"  "Vagina," 
"  Vulva,"  &c.) 

adenoid,  277 

causing  hemorrhage,  89 
leucorrhoea,  80 


INDEX    OF    SUBJECTS. 


789 


Typhoid,  91,  172.  177,  243,  244 
Typhus,  244 


Ulceration,  91 

definition  of,  419 

malignant,  219 
Umbilical  cord,  prolapse  of,  83 
Urea  in  ovarian  cysts,  289 
Urethra,  compression  of,  185 

dilatation  of.  178 

disease  of,  100,  765 

veins  of,  61 
Urine,  albumen  in,  337,  374 

albuminous,  and  containing  bile,  242 

changes  in,  when  kidney  diseased,  315 

containing  pus,  300 

retention  of  {vide  "  Retention  ") 

suppression  of,  367 
Urinasmia,  297,  719 

Uterine  canal,  closure  or  deviation  of,  110 
Uterine  colic,  195,  203,  232,  352 

Uterus,   absence   of,   39,    110,    157,  167,    178, 
217 
abrasion  of,  422 
abscess,  439 
amputation  of,  631 
anomalies  of  consistency,  476 
anteflexion  of,  199,  201,  203,  215,  580 
anteversion   of,    37,   100,    138,    199,   580, 

581 
artificial   eschar   on   vaginal-portion    by 

potassa  cum  calce,  259,  268 
atresia  of,  176,  250,  352,  354 
atrophic  involution  of,  106,  110,  402 
axis  of,  140 
bifid,  38,  43,  111,  178 
blood-clots  retained  in,  200 
broad  ligaments  of,    29,    33,    38,   48,    58 

{vide  "  Broad  Ligament  ") 
bulk,  sensitiveness,  and  mobility  of,  137 
cancer,  description  of,  701 

affects  cervix,  717 

age  of  prevalence,  702 

amputation  of  cervix,  728,  730 

blood  poison,  719 

cancroid,  710 

cauliflower  excrescence,  710 

causes  peritonitis,  708 

cauteries,  732 

compresses  pelvic  and  abdominal 
vessels,  719 

contagious,  703 

"  corroding  ulcer,''  715 

curability,  associated  diatheses,  701 

danger  of,  734 

diagnosis,  721 

diet  in,  738 

duration,  717,  726 

epithelioma,  708 

expulsion  of  diseased  uterus,  718 

forms  of,  705 

gangrene  frequent,  704 

hemorrhage,  719 

hemorrhage,  pain,  odor,  dysuria, 
fixing  of  uterus,  discharge,  &c.. 
722,  723,  724 

intra-uterine,  725 

invades  lymphatics,  715 

kidney  affected,  704 

medullary  or  encephaloid,  705 


Uterus,  cancer  of,  myxoma,  715 

operations  for,  731 

pain  in,  722 

pepsin  in,  734 

perforation,  721 

prognosis,  725 

scirrhous  or  fibrous,  714 

splndle-cell  sarcoma,  713 

sudden  death,  720 

terminations,  spontaneous  cure,  717 

thrombosis    and  phlegmasia    dolens 
in,  720 

treatment,  727 

of  intra-uterine,  735 

ulcerates,  706 

when  complicating  pregnancy,  717 
cancer  and  prolapsus,  560 
carnosities  of,  473,  716 
casts  of,  228 
catarrh,  453 

senile,  477 
cauliflower  excrescence  of,  710 
cauterizing  os  and  cervix,  264 
cervical  canal,  202 
cervix,  injury  of,  in  labor,  418 
changes  in,  by  menstruation,  149,  151 

mucous  membrane  during  menstrua- 
tion, 228 
clots  retained  in,  84,  149 
congestion  of,    194,    195,   198,   201,   203, 

219,  225,  257,  258,  428 
contraction  of,  driving  fluids  along  Fal- 
lopian tube,  353 
cysts  of,  298 
cystic  endometritis,  474 
danger  of  injecting  astringent  fluids,  191 
deranged  function  of,  65 
development  of  mucous  membrane,  370 
dilatation  of,  181,  402 
dimensions  of,  44 
diphtheritic  membrane  of,  230 
direction  of,  38 
disease  of,  70,  76,  107,  108,  110,  111,  260 

of  mucous  membrane,  453 
displacements  of,  67.  81,  533 

oblique  or  lateral,  578,  579 
distended  cavity,  85,  200 
dragging  of,  252,  308 
elongation  of,  313 

by  pressure  of  ovarian  tumor,  309 

from  fibroid,  or  hydrometra,  312 
engorgement  of,  15],  160,  175,  371 
enlarged,  185,  198,  252,  370,  371 

bulk,  232 

in  extra-uterine  gestation,  363 
epithelium  and  cilia  of,  51,  53 
epithelioma  of,  486,  708 
excessive  involution,  senile  condition  of, 

112 
excrescences  of,  473 
excitation,  value  of,  170,  260 
exfoliated  mucous  membrane  of,  226 
fixing  of,  316,  321.  498,  583,  723 
flexions  of,  177,  195,  204,  206,  215,  352, 

579 
fluxion  of,  760 
fungosities  of,  373,  686 
gangrene  of,  623,  718 
glands  of,  51 
hyperemia  of,  102,  110,  204,  427 

chronic,  108,  112,  428 


790 


INDEX    OP    SUBJECTS. 


Uterus,  hypertrophy  (of  body),   91,  108,  111, 
112,  198,  204,  231 
and  elongation    of  vaginal-portion, 
76,  102,  110,  111,  201,  251 
imparous,  41 

imperfect  development   of,   39,  109,  167, 
173 
involution    of,    92,    159     {vide,    also 
"Metritis") 
inclinations  of,  579 
inflammation  of,  99,  102,  190,  203 

of  vaginal-portion,  101 
inflammatory  congestion  of,  159 
injections  into,  190,  353 
introversion,  621 

prognosis  and  diagnosis,  624 
treatment,  628 

by  amputation,  633 
by  ligature,  634 
by  reduction,  630 
by  the  author's  operation,  636 
inversion  of,  86,  91,  150,  254 
causes  of,  616 

definition   of  acute  and  chronic,  615 
{vide  also  "  Introversion  ") 
involution  impeded,  407 
irritable,  99,  193,  194 
isthmus  of  {vide  "  Os  Internum") 
lateral  reelination  of,  194 
lateriversion  of,  201,  223 
lesions  of  continuity,  478,  511 
ligaments  of,  33,  48 
lowness  of,  102,  111,  198 
lymphatics  and  nerves  of,  55 
malignant  disease   of,  229    {vide    "  Can- 
cer") 
mobility  of,  37,  38,  ]  03,  141 
mucous  membrane  of,  50,  53 

hj'perplasia  of,  112,  231,  232 
shedding  of,  228 
muscular  walls  of  (3  layers),  66 
neuralgia  of,  99 
nutation  of,  579 

opening  cavity  in  occlusion,  191 
OS  externum  (vide  "  Os  Tincse  ") 
OS  internum,  43,  44,  202 

constriction  (cause  of),  50 
dilatation   of,  its  fallacy  in  dysmen- 

orrhoea,  206 
flexion  of,  352 
phthisis  of,  697 
plugging  of,  177 
polypus,  definition  of,  676 
containing  hair,  686 
cystic,  683 
degeneration  of,  680 
diagnosis,  687 
fibrinous,  92,  95,  686 
fibroid  or  myoma,  677 
forms  of,  676 
glandular  or  mucous,  682 
hemorrhage,  680 
hypertrophic,  544,  548,  684 
intra-uterine,  200,  679 
placental,  92,  686 
symptoms  of,  680 
treatment,  688 

by  ecraseur,  694 
by  polyptorae,  692 
by  strangulation,  689 

death  from,  689 
by  torsion  and  excision,  690 


Uterus,  polypus,  vaseula,r,  686 

vascularity  of,  680 
position  of,  36 

pregnant,  and  ascites,  305,  306 
procidentia,  534 

course  of,  555 

etiology  of,  552 
prolapsus  of,  37,  101,  150,  235,  352,  534 

diagnosis  of,  558,  559 

operations  for,  571,  672 

treatment  of,  560 
pushing  forward  of,  322,  326,  627 
retention  of  fluids  in,  78,  175,  602 

diagnosis  of,  608 

treatment  of,  612 
retroflexion  of,    93,    100,    113,    138,  145, 
180,  191,  195,  199,  200,   201,  204,  206. 
215,  233,  253,  268,  595 
retroversion   of,   36,    82,    100,   138,    141, 
184,  186,  201,  233,  236,  253,  261, 
365,  536,  595 

treatment  of,  597 

of  gravid,  and  diagnosis,  365 
round  ligament  of,  35 
rudimentary,  246 
rupture  of,  182,  512 

from  obstruction  to  labor  by  ovarian 
cyst,  305 
senile  atrophy  of,  153,  177,  189,  235,  249 

catarrh  of  mucous  membrane,  249, 
477 

occlusion  of,  179,  191 

prolapse  of,  85 
sinuses  of,  64 
size  and  growth  of,  39 
stenosis  and  atresia  of,  93,  192 

by  flexion,  199 
structure  of,  48 
sub-involution  of,  194,  408 
super-involution  of,  417 
suppuration  (inflammation  of),  328 
supra  vaginal-portion,  40 
tenderness  and  swelling  of,  263 
tubercle  of,  696 
tuberculous  deposit  in,  350 
tumors,  fibroid,  640 

become  polypi,  645 

detachment  from  external  surface  of 
uterus,  648 

development  and  decay  of  fibroids, 
653 

earthy  or  bony,  664 

effects  of  fibroids,  665 

erectile,  662 

expulsion  of,  646 

fibro-cystic,  660 

medicines  in,  666 

nature  of,  641 

position  and  shape  of,  643 

question  of  marriage,  666 

recurrent  fibroid,  651 

single  or  conglomerate,  643 

source  of  hemorrhage  from,  656,  659 

styptics,  670 

subcutaneous   injection    of    ergotin, 
668 

symptoms  and  diagnosis,  661 

synonyms,  640 

treatment,  666 

by  dilatation  of  cervix,  669 
by  disintegration,  673 
by  enucleation,  670 


INDEX    OF    SUBJECTS. 


791 


Uterus,  tumors  of,  treatment  by  oxytocics,  671 
by  gastrotomy   and    ablation  of 

uterus,  673 
by  pressure,  668 
ulceration  of,  112,  419 
undeveloped,  188 
utero-sacral  ligament  of,  36 
utero-vesical  ligament  of,  36 
versions  and  flexions  of.    110,    111,   184, 

579 
v;essels  and  distribution   of,  41,    42,   49, 

50,  53 
walls,  measurement  of,  44 
weight,  surfaces,  <tc.,  39,  40 
wounds  of,  92 


Vagina,  19,  56 

absence  of,  101,  178,  189,  191 

artificial,  217 

atresia  of,  103,  176,   186,   188,   190,   191, 

355,  753 
and  stenosis,  93,  110 
atrophic  involution,  106,  743,  745 
bifid,  110 

bursting  of  roof,  303 
cancer  of,  753 
casts  of,  230.  744 

changes  in  by  menstruation,  148,   149 
cicatricial  closing  after  labor,    184,   744, 

746 
columns  and  rugae  of,  58 
contraction  of,  102,  745 
deranged  function  of,  65 
development  of,  61 
dilatation  of,  181,  750 
diphtheritic  membrane  of,  230,  741 
diseases  of,  107,  108,  739 
displacements  of,  742 
ending  in  cul-de-sac,  157,  186 
exfoliation  of  mucous  membrane  by  per- 

chloride  of  iron,  230 
fistula,  743,  745 

operations  for,  747 
glands  of,  enlarged,  321 
hsematoma  of,  753 
hemorrhage  from,  743 
hernia  of,  742 
hypertrophy  of  walls,  183 
imperfection  of,  102,  111 
inflammation  of,  103,  203,  740 
laceration  of,  742 

mucous  membrane  of,  58,  59,  60,  74 
muscular  tunic,  60 
orifice  of,  wanting,  157 
plugging  of,  189,  211,  214,  216 

and  inconveniences,  94,  105 
prolapse  of,  322 
pruritus  of,  758 
relaxation  of,  252 

roof-stretching  of,  305,  322,  370,  371 
sloughing  of,  185,  744,  745 
sphincter,  division  of,  105 
strait  of.  57 
structure  of,  59 
syphilitic  sores,  744 
tubercle  of,  744 
tumors,  cystic,  fibroid,  752 
unhealthy  secretion  of.  111 
uses,  size,  situation,  &c.,  56,  57 


Vagina,  venous  plexuses  of,  58 

vessels,  nerves,  and  lymphatics  of,  61 

vulvar  orifice,  and  situation  of,  59 

wounds  of,  92,  742 
Vaginal  injections,  80 

portion  of  cervix,  42,  137,  210,  218 
hypertrophy  of,  538 

operation  for,  639 
projection  of,  and  small  os,  194,   201 

rest,  105,  258 

roof-stretching,  305,  579 
Vaginismus,  103,  203 
Vaginitis,  72,  740 

diphtheritic,  741 

in  adults  and  in  children,  188 
Variola  {vide  "  Small-pox  ") 
Vertigo,  158,  235,  239,  245 
Vesico-vaginal  fistula,  86,  111,  743 
Vesiculite  (simple  and  grave),  261 
Vestibule,  64 

veins  of,  61 
Vitellus,  vitelline  membrane,  24 
Vomiting,  195,  203,   205,  208,   223,  242,  257, 
265,  292,  333,  334,   343,   345,  347,  349, 
375 

significance  of,  175,  183 

stercoraceous,  297 
Vulva,  19,  61,  106,  744 

abscess  of,  756 

atresia  of  (3  kinds),  103,  110,  176 
causes,  176,  355,  744 

atresia  and  stenosis,  93 

atrophic  involution,  106 

cancer,  764 

cysts,  761 

description  of,  61 

diphtheritic  membrane  of,  230 

diseases  of,  108,  754 

eczema,  758 

fissures  of,  104,  767 

folliculitis,  759 

glands  of,  755,  756  (vide,  "  Bartholini's  ") 

hemorrhagic,  hsematoma,  756 

herpes,  758 

hypertrophy,  760,  762 

inflammation   of,    or   vulvitis,    104,   755, 
759 

lupus,  764 

lupus  exedens,  764 

melanosis  of,  765 

neuromata,  761 

pruritus  of,  758 

sensitiveness  of,  104 

sphincter,  contractions  of,  103 

syphilitic,  763 

thrombus  of,  756 

varix  of,  92,  757 

vascular  outgrowths,  761 

of  meatus  urinarius,  765 

veins  of,  61 

warts  of,  762 

wounds  of,  92 
Vulsella,  339 


Watery  discharges,  83,  91 

Wells's  trocar,  331,  340 

Wire  ecraseur,  117,  125 

Woodhall  Spa,  489,  503 

Wright's  intra-uterine  stem,  211,  215,  612 


EERATA. 

Page  43,  Fig.  15,  for  "shining,"  read  "thinning." 
"  59,  for  "  myrtiformEe,"  read  "  myrtiformes." 
"      108,  109,  for  "Captain  Galton,"  read  "Francis  Galton." 


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The  Medical  News  and  Library,  monthly  (384  pp.  per  annum),  and  -{    per  annum 
The  Supplement  to  the  Medical  News  and  Library,  monthly  (592    j    -^  advance 
pages  per  annum).  '  [ 

SEPAMATE  SJTBSCltlPTIONS  TO 

The  American  Journal  of  the  Medical  Sciences,  subject  to  postage  when  not  paid 

for  in  advance.  Five  Dollars. 
The  Medical  News  and  Library,  free  of  postage,  in  advance.  One  Dollar. 
The  Medical  News  and  Library,  with  the  Supplement,  free  of  postage,  in  advance, 

Three  Dollars  and  a  Half. 
It  is  manifest  that  only  a  very  wide  circulation  can  enable  so  vast  an  amount  of 
valuable  practical  matter  to  be  supplied  at  a  price  so  unprecedentedly  low.  The  pub- 
lisher, therefore,  has  much  gratification  in  stating  that  the  rapid  and  steady  increase 
in  the  subscription  list  promises  to  render  the  enterprise  a  permanent  one,  and  it  is 
with  especial  pleasure  that  he  acknowledges  the  valuable  assistance  spontaneously 
rpudered  by  so  many  of  the  old  subscribers  to  the  "Journal,"  who  have  kindly  made 
known  among  their  friends  the  advantages  thus  offered  and  have  induced  them  to 
subscribe.  Relying  upon  a  continuance  of  these  friendly  exertions,  he  hopes  to  be 
able  to  maintain  the  unexampled  rates  at  which  these  works  are  now  offered,  and  to 


(For  "  The  American  Chemist,"  see  p.  11 .) 
■;For  "  The  Obstetrical  Journal,'"  see  p.  22  ) 


2         Henry  C.  Lea's  Publications — (Am.  JourrL  Med.  Sciences). 

Biicceed  in  his  endeavor  to  place  upon  the  table  of  every  reading  practitioner  in  the 
United  States  the  equivalent  of  three  large  octavo  volumes,  a  the  comparatively 
trifling  cost  of  Six  Dollars  per  annum. 

These  periodicals  are  universally  known  for  their  high  professional  standing  in  their 
several  spheres. 

I. 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES, 

Edited  by  ISAAC  HAYS,  M.  D., 

\i  published  Quarterly,  on  the  first  of  January,  April,  July,  and  October.  Each 
number  contains  nearly  three  hundred  large  octavo  pages,  appropriately  illustrated, 
wherever  necessary.  It  has  now  been  issued  regularly  for  over  fifty  years,  during 
almost  the  whole  of  which  time  it  has  been  under  the  control  of  the  present  editor. 
Throughout  this  long  period,  it  has  maintained  its  position  in  the  highest  rank  of 
medical  periodicals  both  at  home  and  abroad,  and  has  received  the  cordial  support  of 
the  entire  profession  in  this  country.  Among  its  Collaborators  will  be  found  a  large 
number  of  the  most  distinguished  names  of  the  profession  in  every  section  of  the 
United  States,  rendering  the  department  devoted  to 

ORIOINAL     COMMUNICATIONS 

full  of  varied  and  important  matter,  of  great  interest  to  all  practitioners.  Thus,  during 
ib73,  articles  have  appeared  in  its  pages  from  nearly  one  hundred  gentlemen  of  the 
highest  standing  in  the  profession  throughout  the  United  States.* 

Following  this  is  the  "Review  Department,"  containing  extended  and  impartial 
reviews  of  all  important  new  works,  together  with  numerous  elaborate  "Analytical 
AND  Bibliographical  Notices"  of  nearly  all  the  medical  publications  of  the  day. 

This  is  followed  by  the  "  Quarterly  Summary  of  Improvements  and  Discoveries 
IN  THE  Medical  Sciences,"  classified  and  arranged  under  different  heads,  presenting 
a  very  complete  digest  of  all  that  is  new  and  interesting  to  the  physician,  abroad  as 
well  as  at  home. 

Thus,  during  the  year  1873,  the  "  Jottbnal"  furnished  to  its  subscribers  Seventy-seven 
Original  Communications,  One  Hundred  and  Twenty-five  Reviews  and  Bibliograph- 
ical Notices,  and  Two  Hundred  and  Ninety-four  articles  in  the  Quarterly  Summaries, 
making  a  total  of  about  Five  Hundred  articles  emanating  from  the  best  profes- 
sional minds  in  America  and  Europe. 

That  the  efforts  thus  made  to  maintain  the  high  reputation  of  the  "  Journal"  are 
successful,  is  shown  by  the  position  accorded  to  it  in  both  America  and  Europe  as  a 
national  exponent  of  medical  progress  : — 

Dr.  Hays  keeps  Ms  great  American  Quarterly,  in 
which  he  is  now  assisted  by  Dr.  Minis  Hays,  at  the 
head  of  his  country's  medical  periodicals.— DuWira 
Medical  Frees  and  Circular,  March  8,  1871. 

Of  English  periodicals  the  Lancet,  and  of  American 
the  Am.  Journal  of  the  Medical  Sciences,  are  to  be 
regarded  as  necessities  to  the  reading  practitioner. — 
N.  Y.  Medical  Gazette,  Jan.  7,  1871. 

The  American  Journal  of  the  Medical  Sciences 
yields  to  none  in  the  amount  of  original  and  borrowed 
mailer  it  contains,  and  has  established  for  itsell  a 

And  by  the  fact,  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to 
Ihe  publisher  at  the  Yienna  Exhibition  in  ib78. 

The  subscription  price  of  the  "American  Journal  of  the  Medical  Sciences  "  has 
never  been  raised,  during  its  long  career.  It  is  still  Five  Dollars  per  annum  ;  and 
when  paid  for  in  advance,  the  subscriber  receives  in  addition  the  "  Medical  News  and 
Library,"  making  in  all  about  150U  large  octavo  pages  per  annum,  free  of  postage. 

II. 

THE  MEDICAL  NEWS  AND  LIBRARY 

IS  a  monthly  periodical  of  Thirty-two  large  octavo  pages,  making  384  pages  per 
annum.  Its  "News  Department"  presents  the  current  information  of  the  day,  with 
Clinical  Lectures  and  Hospital  Gleanings;  while  the  "  Library  Department  '  is  de- 
voted to  publishing  standard  works  on  the  various  branches  of  medical  science,  paged 

*  Communications  are  invited  from  gentlemen  in  all  parts  of  the  country.    Elaborate  articles  inserted 

by  the  Editor  are  paid  for  by  the  Publisher. 


reputation  in  every  country  where  medicine  is  cul- 
tivated as  a  science. — Brit,  and  For.  Med.-Ohirurg. 
Review,  April,  1871. 

This,  if  not  the  best,  is  one  of  the  best-conducted 
medical  quarterlies  in  the  English  language,  and  the 
pieseat  number  is  not  by  any  means  interior  to  its 
predecessors. — London  Lancet,  Aug.  23,  1873. 

Almost  the  only  one  that  circulates  everywhere, 
all  over  the  Union  and  in  Europe. — London  Medical 
Times,  Sept.  5,  1868. 


Henry  C.  Lea's  Publications — (Am.  Journ.  Med.  Sciences).        3 

separately,  so  that  they  can  be  removed  and  bound  on  completion.  In  this  manner 
subscribers  have  received,  without  expense,  such  works  as  "  Watson's  Practice," 
"  Todd  and  Bowman's  Physiology,"  "West  on  Children,"  "  Malgaigne's  Surgery," 
&c.  &c.  In  July,  1873,  was  commenced  the  publication  of  Dr.  Wilson  Fox's  valu- 
able work  '•  On  the  Diseases  of  the  Stomach"  (see  p.  16).  New  subscribers,  commenc- 
ing with  1874,  can  obtain  the  portion  printed  in  1873  by  a  remittance  of  50  cents,  if 
promptly  made. 

As  stated  above,  the  subscription  price  of  the  "Medical  News  and  Library"  is 
One  Dollar  per  annum  in  advance ;  and  it  is  furnished  without  charge  to  all  advance 
paying  subscribers  to  the  "American  Journal  of  the  Medical  Sciences." 

III. 

SUPPLEMENT  TO  THE  MEDICAL  NEWS  AND  LIBRARY. 

The  publication  in  England  of  Banking's  "  Half-Yrarly  Abstract  of  the  Me- 
dical Sciences"  having  ceased  with  the  volume  for  January,  1874,  its  place  will  be 
supplied  in  this  country  by  a  monthly  Supplement  to  the  "Medical  News  and 
Library,"  containing  forty-eight  large  octavo  pages  each  month,  thus  furnishing 
in  the  course  of  the  year  about  six  hundred  pages,  the  same  amount  of  matter  as 
heretofore  embraced  in  the  Half-Yearly  Abstract.  As  the  discontinuance  of  the 
Abstract  arose  from  the  multiplication  of  journals  appearing  more  frequently  and 
presenting  the  same  character  of  material,  it  has  been  thought  that  this  plan  of 
monthly  issues  will  better  meet  the  wants  of  subscribers  who  will  thus  receive  earlier 
intelligence  of  the  improvements  and  discoveries  in  the  medical  sciences.  The  aim 
of  the  Supplement  will  be  to  present  a  careful  abstract  of  all  that  is  new  and  impor- 
tant in  the  medical  journalism  of  the  world,  and  all  the  prominent  professional  peri- 
odicals of  both  hemispheres  will  be  at  the  disposal  of  the  Editors. 

Subscribers  desiring  to  bind  the  Supplement,  will  receive  on  application  at  the  end 
of  each  year,  a  cloth  cover,  gilt  lettered,  for  the  purpose,  or  it  will  be  sent  free  by 
mail  on  receipt  of  the  postage,  which,  under  existing  laws,  will  be  six  cents. 

The  subscription  to  the  "Mkdical  News"  and  its  "'  Supplement,"  free  of  postage, 
will  be  Three  Dollars  and  a  Haifa  year,  in  advance,  containing  in  all  nearly  a  thou- 
sand pages  per  annum. 

As  stated  above,  however,  they  will  be  supplied  in  conjunction  with  the  "American 
Journal  of  the  Medical  Sciences,"  making  in  all  about  Twenty-one  Hundred  pages 
per  annum,  the  whole /7ee  of  j'odage,  for  Six  Dollars  a  year,  in  advance. 

As  the  January  volume  of  the  "  Half-Yearly  Abstract"  has  supplied  to  subscri- 
bers what  is  due  to  them  for  half  of  the  year  1874,  the  Supplement  to  the  Ncips  and 
Library  will  be  commenced  with  July,  1874. 

In  this  effort  to  bring  so  large  an  amount  of  practical  information  within  the  reach 
of  every  member  of  the  profession,  the  publisher  confidently  anticipates  the  friendly 
aid  of  all  who  are  interested  in  the  dissemination  of  sound  medical  literature.  He 
trusts,  especially,  that  the  subscribers  to  the  "American  Medical  Journal"  will  call 
the  attention  of  their  acquaintances  to  the  advantages  thus  offered,  and  that  he  will 
be  sustained  in  the  endeavor  to  permanently  establish  medical  periodical  literature  on 
a  footing  of  cheapness  never  heretofore  attempted. 

FBEMIUM  FOB  NEW  SUBSCRIBERS. 

Any  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  1874,  one  of 
which  must  be  for  a  neio  subscriber,  will  receive  as  a  premium,  free  by  mail,  a  copy  of 
Sturges'  Clinical  Medicine  (for  advertisement  of  which  see  p.  14),  or  of  the  new  edi-. 
tion  of  Swayne's  Obstktric  Aphorisms  (see  p.  24),  or  of  Tanner's  Clinical  Manual 
(see  p.  5J,  or  of  Chambers'  Restorative  Medicine  (see  p.  15),  or  of  West  on  Nerv- 
ous Disorders  of  Children  (see  p.  21). 

*♦*  (ientlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1874,  as  the  constant  increase  in  the  subscription  list  almost 
always  exhausts  the  quantity  printed  shortly  after  publication. 

^^  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
to  tJie  order  of  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
"Journal"  may  be  made  at  the  risk  of  the  publisher,  by  forwarding  in  registered 
letters.    Address, 

HENRY  C.  LEA, 
Nob.  706  and  708  Sansom  St.,  Philadklpeia  Pa 


Henry  C.  Lea's  Publications— (Dictionaries). 


jyUNGLISON  [ROBLEY),  M.D., 

Lnte  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

MEDICAL  LEXICON;  A  Dictionary  of  Medical  Science:  Con- 
taining a  concise  explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.  Notices  of  Climate  and  of  Mineral  Waters;  Formulas  for 
Officinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes ;  so  as  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.  A  New  Edition.  Thoroughly  Revised,  and  very  greatly  Mod- 
ified and  Augmented  By  Richard  J.  Dukglison,  M.D.  In  one  very  large  and  hand- 
some royal  octavo  volume  of  over  1100  pages.  Cloth,  $6  60  ;  leather,  raised  bands,  $7  60. 
{Just  Ready.) 

The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  under  each,  a  condensed  view  of  its  various  medical  relation"?, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.  Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it-has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en- 
viable reputation.  During  the  t' n  years  which  have  elapsed  since  the  List  revision,  the  additions 
to  the  nomenjlature  of  the  medical  sciences  have  been  greater  than  perhaps  in  any  similar  period 
of  the  past,  and  up  to  the  time  of  his  death  the  author  labored  assiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  practi:ioner.  Since  then,  the  editor  has  been 
equally  industrious,  so  that  the  additions  to  the  vocabulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typigraphical  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  and  every  care  has  been  taken  with  the  mechanical  execution.  The 
work  has  been  printed  on  new  type,  small  but  exceedingly  clear,  with  an  enlarged  page,  so  that 
the  additions  have  been  incorporated  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 


A  book  well  known  to  our  readers,  and  of  which 
every  American  ought  to  be  proud.  When  the  learned 
author  of  the  work  passed  away,  probably  all  of  us 
feared  lest  the  hook  should  not  maintain  its  place 
iu  the  advaucinp  science  whose  terms  it  defines.  For- 
tunately, Dr.  Richard  .T.  Dunglison,  having  assisted  his 
father  in  the  I'evision  of  several  editions  of  the  work, 
and  having  been,  therefore,  trained  in  the  methods  and 
imbued  with  the  spirit  of  the  book,  has  been  able  to 
edit  it,  not  in  the  patchwork  manner  so  dear  to  the 
heart  of  book  editors,  so  repulsive  to  the  taste  of  intel- 
ligent hook  readers,  but  to  edit  it  as  a  work  of  the  kind 
should  be  edited — to  carry  it  on  .steadily,  without  jar 
or  interruption,  along  the  groove.s  of  thought  it  has 
travelled  during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr  Dunglison  has  assumed  and  car- 
ried through,  it  is  only  necessary  to  stale  that  more 
than  six  thousand  new  subjects  have  been  added  in  the 
present  edition.  Without  occupying  more  space  with  ihe 
theme,  we  congratulate  the  editor  on  the  successful 
completion  of  his  labors,  and  hope  he  may  reap  the  well- 
earned  reward  of  profit  and  honor. — Fliila.  Med.  Timea, 
Jan  3, 1874. 

About  the  first  book  purchased  by  the  medical  stu- 
dent is  the  Medical  Dictionary.  The  lexicon  explana- 
tory of  technical  terms  is  simply  a  sine  qua  non.  In  a 
science  so  extensive,  and  with  such  collaterals  as  medi- 
cine, it  is  as  much  a  necessity  also  to  the  practising 
physician.  To  meet  the  wants  of  students  and  most 
physicians,  the  dictionary  must  he  condensed  while 
comprehensive,  and  practical  while  perspicacious.  It 
was  because  Dunglisou's  met  these  indications  that  it 
became  at  once  the  dictionary  of  general  use  wherever 
medicine  was  studied  in  the  English  lansuaire.  In  no 
former  revision  have  the  alterations  and  additions  been 
so  great.  More  Ihan  six  thousand  new  subjects  and  fernis 
have  been  added.  The  chief  terms  have  been  set  in  black 
letter,  while  ihe  derivatives  follow  iu  small  caps:  an 
arrangement  which  greatly  facilitates  reference.  We 
may  safely  confirm  the  hope  ventured  by  the  editor 
"  that  the  work,  which  l)Osses^('S  for  him  a  filial  as  weil 
a«  an  individual  interest,  will  be  found  worthy  a  con- 
tinuance of  the  position  so  long  accorded  to  it  as  a 
standard  &wthoiity ."—Cincinnati  Clinic,  Jan.  10,  187-t. 


We  are  glad  to  see  a  new  edition  of  this  invaluable 
work,  and  to  find  that  it  has  been  so  thoroughly  revised, 
and  so  greatly  improved.  The  dictionary,  in  its  pre- 
sent form,  is  a  medical  library  in  itself,  and  one  of 
which  every  physician  should  be  possessed. — N.  T.  Med. 
Journal,  Keb.  IbTl. 

With  a  history  of  forty  years  of  unexampled  success 
and  universal  indorsement  by  the  medical  profession  of 
the  western  continent,  it  would  be  presumption  in  any 
living  metlieal  American  to  essay  its  review.  No  re- 
viewer, however  able,  can  add  to  its  fame ;  no  captious 
critic,  however  caustic,  can  remove  a  single  stone  from 
its  firm  and  enduring  foundation.  It  is  destined,  as  a 
colossal  monument,  to  perpetuate  the  solid  and  richly 
deserved  fame  of  Robley  Dunglison  to  coming  genei-a- 
tions.  The  large  additions  made  to  the  vocabulary,  we 
think,  will  be  welcomed  by  the  profession  as  supplying 
the  want  of  a  lexicon  fully  up  with  the  march  of  sci- 
ence, which  has  been  increasingly  felt  for  some  years 
past.  The  accentuation  of  terms  is  very  complete,  and, 
as  far  as  we  have  been  able  to  examine  it,  very  excel- 
lent. We  hope  it  may  be  the  means  of  securing  greater 
uniformity  of  prnnunciation  among  medical  men. — At- 
lanta Med.  and  Surg.  Journ.,  I'eb.  1S74. 

It  would  be  mere  waste  of  words  in  us  to  express 
>MX  admiration  of  a  work  which  is  so  universally 
and  deservedly  appreciated.  The  most  admirable 
svork  of  its  kind  in  the  English  language. —  rlasgow 
Medical  Journal,  January,  1866. 

A  work  to  which  there  is  no  equal  in  the  English 
language. — Edinburgh  Medical  Journal. 

Few  works  of  the  ciass  exhibit  a  grander  monument 
jf  patient  research  and  of  scientific  lore.  The  extent 
of  the  sale  of  this  lexicon  is  sutficient  to  testify  to  its 
risefuiness,  and  to  the  great  service  conferred  by  Dr. 
Robley  Dunglison  on  the  profession,  and  indeed  on 
others,  by  its  issue. — London  Lancet,  May  13,  1865. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent  of 
references. — London  Medical  Oazette. 


TJOBLYN  [RICHARD  D.),  M.D. 

A  DICTIONARY  OF  THE  TEKMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.     Revised,  with  numerous  additions,  by  Isaac    Hays, 
M.D.,  Editor  of  the  "American  Journal  of  the  Medical  Sciences."     In  one  large  royal 
12mo.  volume  of  over  500  double-columned  pages  ;  extra  cloth,  i^l  50  ;  leather,  $2  00. 
It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upontne  amdent's  tabl«.— SoMfiern 
Med.  and  Surg.  Journal. 


Henry  C.  Lea's  Publications — (Manuals'). 


J^EILL  {JOHN),  M.D., 


may  make  it  his  constant  pocket  companion. —  West- 
ern Lancet. 

In  the  rapid  course  of  lectures,  where  work  for  the 
students  is  heavy,  and  review  necessary  for  an  exa- 
mination, a  compend  is  not  only  valuable,  but  it  is 
almost  a  sine  qtta  non.  The  one  before  us  is,  in  most 
of  the  divisions,  themost  unexceptionable  of  all  books 
of  the  kind  that  we  know  of.  Of  course  it  is  uselesis 
for  us  to  recommend  it  to  all  last  course  students,  but 
there  is  a  class  to  whom  we  very  sincerely  commend 
this  cheap  book  as  worth  its  weight  in  silver — that 
class  is  the  graduates  in  medicine  of  more  than   ten 


and     ^MITH  {FRANCIS  G.),  M.D., 

Prof,  of  the  Institutes  of  Medicine  in  the  Univ.  of  Penna. 

AN"    ANALYTICAL    COMPENDIUM    OF    THE   VARIOUS 

BRANCHES  OP  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students.     A 

new  edition,  revised  and  improved.    In  one  very  large  and  handsomely  printed  royal  12m(i. 

volume,  of  about  one  thousand  pages,  with  374  wood  cuts,  extra  cloth,  $4;  strongly  bound 

in  leather,  with  raised  bands,  $4  75. 
The  Compend  of  Drs.  Neilland  Smith  is  incompara-  \  clous  factstreasured  up  in  this  little  volume.    Acom- 
bly  the  most  valuable  work  of  its  class  ever  publi-shed  |  plete  portable  library  so  condensed  that  the  student 
In  this  country.    Attempts  have  been  made  in  various 
quarters  to  squeeze  Anatomy,  Physiology,  Surgery, 
the  Practice  of  Medicine,  Obstetrics,  Maieria  Medica, 
snd  Chemistry  into  a  single  manual;  but  the  opera- 
tion has  signally  failed  in  the  hands  of  all  up  to  the 
advent  of  "Neill  and  Smith's"  volume,  which  is  quite 
a,  miracle  of  success.    The  outlines  of  the  whole  are 
admirably  drawn  and  illustrated,  and  the  authors 
are  eminently  entitled  to  the  grateful  consideration 
of  the  student  of  every  class. — N.  0.  Med.  and  Surg. 
J'oxirnal. 

There  are  but  few  students  or  practitioners  of  me- 
dicine unacquainted  with  the  former  editions  of  this  |  years'  standing,  who  have  not  studied  medicine 
unas.suming  though  highly  instructive  work.  The  i  since.  They  will  perhaps  find  out  from  it  that  the 
whole  science  of  medicine  appears  to  have  been  sifted,  |  science  is  not  exactly  now  what  it  was  when  they 
as  the  gold-bearing  sands  of  El  Dorado,  and  the  pre-  >  left  it  off. — The  Stethoscope.  I 

TTARTSHORNE  {HENRY),  M.  D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A    CONSPECTUS    OF    THE    MEDICAL    SCIENCES;    containing 

Handbooks  on   Anatomy,   Physiology,  Chemistry,  Materia   Medica,    Practical   Medicine, 

Surgery,  and  Obstetrics.    Second  Edition,  thoroughly  revised  and  improved.     In  one  large 

royal  12mo.  volume  of  more  than  1000  closely  printed  pages,  with  over  300  illustrations  on 

wood.      (P?-fparing.) 

The  favor  with  which  this  work  has  been  received  has  stimulated   the  author  in  its  revision  to 

render  it  in  every  way  fitted  to  meet  the  wants  of  the  student,  or  of  the  practitioner  desirous  to 

refresh  his  acquaintance  with  the  various  departments  of  medical  science.    The  various  sections  have 

been  brought  up  to  a  level  with  the  existing  knowledge  of  the  day,  while  preserving  the  condenta 

tion  of  form  by  which  so  vast  an  accumulation  of  facts  have  been  brought  within  so  narrow  a 

compass. 

This  work  is  a  remarkably  complete  one  in  its  way, 
and  comes  nearer  to  our  idea  of  what  a  Conspectus 
should  be  than  any  we  have  yet  seen.  Prof.  Harts- 
horne,  with  a  commendable  forethought,  intrusted 
the  preparation  of  many  of  the  chapters  on  special 


subjects  to  experts,  reserving  only  anatomy,  physio- 
logy, and  practice  of  medicine  to  himself.  As  a  result 
we  have  every  department  worked  up  to  the  latest 
dale  and  in  a  refreshingly  concise  and  lucid  manner. 
There  are  an  immense  amount  of  illustrations  scat- 
tered throughout  the  work,  and  although  they  have 
often  been  seen  before  in  the  various  works  upon  gen- 
eral and  special  subjects,  yet  they  will  be  none  the 


less  valuable  to  the  beginner.  Every  medical  student 
who  desires  a  reliable  refresher  to  his  memory  when 
the  pressure  of  lectures  and  other  college  work  crowds 
to  prevent  him  from  having  an  opportunity  to  drink 
deeper  in  the  larger  works,  will  find  this  one  of  tha 
greatest  utility.  It  is  thoroughly  trustworthy  from 
beginning  to  end  ;  and  as  we  have  before  intimated, 
a  remarkably  truthful  outliue  sketch  of  the  present 
state  of  medical  science.  We  could  hardly  expect  it 
should  be  otherwise,  however,  under  the  charge  of 
such  a  thorough  medical  scholar  as  the  author  haa 
already  proved  himself  to  be. — 2^.  York  Med.  Record, 
March  15,  1869. 


J  VDLOW{J.l£:),  M.D. 

A   MANUAL   OF   EXAMINATIONS   upon   Anatomy,   Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages,  extra  cloth,  $3  25;  leather,  $3  75. 
The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
able for  the  oflBce  examination  of  students,  and  for  those  preparing  for  graduation. 

/TANNER  {THOMAS  HA  WKES),  M.  D.,  ^c. 

A 'manual  of  clinical  MEDICINE  AND  PHYSICAL  DIAG- 

NOSIS.     Third  American  from  the  Second  London  Edition.     Revised  and  Enlarged  by 

Tilbury  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospital, 

&o.    In  one  neat  volume  small  ]2mo.,  of  about  376  pages,  extra  cloth.   $160.    {Just  Issued.) 

***  By  reference  to  the  "  Prospectus  of  Journal"  on  page  3,  it  will  be  seen  that  this  work  is 

offered  as  a  premium  for  procuring  new  subscribers  to  the  "American  Journal  of  the  MsDiCAii 

Sciences." 


Taken  as  a  whole,  it  is  the  most  compact  vade  me- 
cum  for  the  use  of  the  advanced  student  and  junior 
practitioner  with  which  we  are  acquainted. — Boston 
Med.  and  Surg.  Journal,  Sept.  22,  1870. 

It  contains  so  much  that  is  valuable,  presented  in 
so  attractive  a  form,  that  it  can  hardly  be  spared 
even  in  the  presence  of  more  full  and  complete  works. 
The  additions  made  to  the  volume  by  Mr.  Fox  very 
materially  enhance  its  value,  and  almost  make  it  a 
new  work.  Its  convenient  size  make.s  it  a  valuable 
companion  to  the  country  practitioner,  and  if  con- 
stantly carried  by  him,  would  often  render  him  good 
service,  and  relieve  many  a  doubt  and  perplexity. — 
Leavenworth  Med.  Herald,  July,  1870. 


The  objections  commonly,  and  justly,  urged  against 
the  general  run  of  "compends,"  "conspectuses,"  and 
other  aids  to  indolence,  are  not  applicable  to  this  little 
volume,  which  contains  in  concise  phrase  just  those 
practical  details  tbat  are  of  most  use  in  daily  diag- 
nosis, but  which  the  young  practitioner  finds  it  difll- 
cult  to  carry  always  in  his  memory  without  some 
quickly  accessible  means  of  reference.  Altogether, 
the  book  is  one  which  we  can  heartily  commend  to 
those  who  have  not  opportunity  for  extensive  read- 
ing, or  who,  having  read  much,  still  wish  an  occa- 
sional practical  reminder. — N.  T.  Med.  Gazette,  Nov. 
10,  1870. 


Henry  C.  Lea's  Publications — {Anatomy). 


fiRAY  [HENRY),  F.R.S., 

^^  Lecturer  on  Anatomy  at  St.  George's  EosjMal,  London. 

ANATOiMY,    DESCRIPTIYE    AND    SURGICAL.      The  Drawings  by 

H.  V.  Carter,  M.  D.,  late  Demonstrator  on  Anatomy  at  St.  George's  Hospital ;  the  Dissec- 
tions jointly  by  the  Author  and  Dr.  Carter.     A  new  American,  from  the  fifth  enlarged 
and  improved  London  edition.     In  one  magnificent  imperial  octavo  volume,  of  nearly  900 
pages,  with  465  large  and  elaborate  engravings  on  wood.     Price  in  extra  cloth,  $6  00  ; 
leather,  raised  bands,  $7  00.     {J^lst  Issued.) 
The  author  has  endeavored  in  this  work  to  cover  a  more  extended  range  of  subjects  than  is  cus- 
tomary in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.     The  en 
gravings  form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.    They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room;  while  combining,  as  it  does,  &  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  ofiices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Notwithstanding  the  enlargement  of  this  edition,  it  has  been  kept  at  its  former  very  moderate 
price,  rendering  it  one  of  the  cheapest  works  now  before  the  profession. 

From  time  to  time,  as  successive  editions  have  ap- 
peared, we  have  had  much  pleatiure  in  expressiny 
the  general  judgment  of  the  wnnderful  excellence  of 


The  illustrations  are  heautifully  executed,  and  ren- 
der this  work  an  indispensahle  adjunct  to  the  library 
of  the  surgeon.  This  remark  applies  with  great  force 
to  those  surgeons  practising  at  a  distance  from  our 
lavge  cities,  as  the  opportunity  of  refreshing  their 
mpmory  hy  actual  dissection  is  not  always  attain- 
able.—Canada  Med   Journal,  Aug.  1870. 

The  work  is  too  well  known  and  appreciated  by  the 
profession  to  need  any  comment.  No  medical  man 
can  afford  to  be  without  it,  if  its  only  merit  were  to 
Serve  as  a  reminder  of  that  which  so  soon  becomes 
forgotten,  when  not  called  into  frequent  use,  viz.,  the 
relations  and  names  of  the  complex  organism  of  the 
human  body.  The  present  edition  is  much  improved. 
—  California  Med.  Gazette,  July,  1S70. 

Gray's  Anatomy  has  been  so  long  the  standard  of 
perfection  with  every  student  of  anatomy,  that  we 
need  do  no  more  than  call  attentioo  to  the  improve- 
ment in  the  present  edition. — Detroit  Review  of  Med. 
and  Pharm.,  Aug.  1870. 


Gray's  Anatomy. — Cincinnati  Lancet,  July,  1870. 

Altogether,  it  is  unquestiouably  the  most  compleit 
and  serviceable  text-book  in  anatomy  that  has  ever 
been  presented  to  the  student,  and  forms  a  striking 
contrast  to  the  dry  and  perplexing  volumes  on  the 
same  subject  through  which  their  predecessors  strug- 
gled in  days  gone  by. — N.  Y.  Med.  Record,  June  15, 
1870. 

To  commend  Gray's  Anatomy  to  the  medical  pro- 
fession is  almost  as  much  a  work  of  supererogation 
as  it  would  be  to  give  a  favorable  notice  of  the  Bible 
in  the  religious  press.  To  say  that  it  is  the  most 
complete  and  conveniently  arranged  text  book  of  its 
kind,  is  to  repeat  what  each  generation  of  students 
has  learned  as  a  tradition  of  thf  elders,  and  verified 
by  personal  experience. — N.  Y.  Med.  Gazette,  Dec. 
17,  1870. 


(^MITE  [HENR  Y  H.),  M.D.,         and     TIORNER  (  WILLIAM  E.),  M.D., 

Prof,  of  Surgery  in  the  Univ.  of  Penna. ,  &c.  Late  Prof,  of  Anatomy  in  the  Univ.  of  Penna. ,  Ac 

AN    ANATOMICAL    ATLAS,  illustrative   of  the   Structure  of  the 

Human  Body.  In  one  volume,  large  imperial  octavo,  extra  cloth,  with  about  six  hundred 
and  fifty  beautiful  figures.  $4  60. 
The  plan  of  this  Atlas,  which  renders  it  so  pecn-  I  the  kind  that  has  yet  appeared  ;  and  we  must  add, 
llarly  convenient  for  the  student,  and  its  superb  ar-  |  the  very  beautiful  manner  in  which  it  is  "got  up," 
tistical  execution,  have  been  already  pointed  out.  We  j  is  so  creditable  to  the  country  as  to  be  flattering  to 
must  congratulate  the  student  upon  the  completion  our  national  pride. — American  MedicalJournal. 
of  this  Atlas,  as  it  is  the  most  convenient  work  of  I 

^HARPEY  (  WILLIAM),  M.D.,     and       Q  UAIN  [JONES  Sf  RICHARD). 
HITMAN  ANATOMY.  Revised,  with  Notes  and  Additions,  by  Joseph 

Leidy,  M.D.,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.     Complete  in  two 
large  octavo  volumes,  of  about  1300  pages,  with  511  illustrations;  extra  cloth,  $6  00. 
The  very  low  price  of  this  standard  work,  and  its  completeness  in  all  departments  of  the 'subject, 
should  command  for  it  a  place  in  the  library  of  all  anatomical  students. 


nrODGES  [RICHARD  M.),  M.D., 

Late  Demonstrator  of  Anatomy  in  the  Medical  Department  of  Harvard  University. 

PRACTICAL   DISSECTIONS.     Second  Edition,  thoroughly  revised.     In 

one  neat  royal  12mo.  volume,  half-bound,  $2  00. 
The  object  of  this  work  is  to  present  to  the  anatomical  student  a  clear  and  concise  description 
of  that  which  he  is  expected  to  observe  in  an  ordinary  couise  of  dissections.  The  author  has 
endeavored  to  omit  unnecessary  details,  and  to  present  the  subjejt  in  the  form  which  many  years' 
experience  has  shown  him  to  be  the  most  convenient  and  intelligible  to  the  student.  In  the 
revision  of  the  present  edition,  he  has  sedulously  labored  to  render  the  volume  more  worthy  of 
•■he  favor  with  which  it  has  heretofore  been  received. 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOLOGY.  I      In  2  vols,  flvo  ,  of  over  1000  pages,  with  more  tha- 
Hif^hlh  edition,  extansively  revised  and  modified.  I      300  wood-cuts;  extra  clolh.  *H  00. 


Henry  C.  Lea's  Publications — (Anatomy). 


T^ILSON  ( ERASM US),  F.R.S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.     Edited 

by  W.  H.  GoBRECHT,  M.  D.,  Professor  of  Geueraland  Surgical  Anatomy  in  the  Medical  Col- 
lege of  Ohio.     Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.     In 
one  large  and  handsome  octavo  volume,  ol  over  600  large  pages;  exira  cloth,  $4  00;  lea- 
ther, $5  00. 
The  publisher  trusts  that  the  well-earned  reputation  of  this  long-established  favorite  will  be 
more  than  maintained  by  the  present  edition,     ilesides  a  very  thorough  revision  by  the  author,  it 
has  been  most  carefully  examined  by  the  editor,  and  the  eiforts  of  both  have  been  directed  to  in- 
troducing everything  which  increased  experience  in  its  use  has  suggested  as  desirable  to  render  it 
a  complete  text-book  for  those  seeking  to  obtain  or  to  renew  an  acquaintance  with  Human  Ana- 
tomy.    The  amount  of  additions  which  it  has  thus  received  may  be  estimated  from  the  fact  that 
the  present  edition  contains  over  one-fourth  more  matter  than  the  last,  rendering  a  smaller  type 
and  an  enlarged  page  requisite  to  keep  the  volume  within  a  convenient  size.     The  author  has  not 
only  thus  added  largely  to  the  work,  but  he  has  also  made  alterations  throughout,  wherever  there 
appeared  the  opportunity  of  improving  the  arrangement  or  style,  so  as  to  present  every  fact  in  its 
most  appropriate  manner,  and  to  render  the  whole  as  clear  and  intelligible  as  possible.    The  editor 
has  exercised  the  utmost  caution  to  obtain  entire  accuracy  in  the  text,  and  has  largely  increased 
the  number  of  illustrations,  of  which  there  are  about  one  hundred  and  fifty  more  in  this  edition 
than  in  the  last,  thus  bringing  distinctly  before  the  eye  of  the  student  everything  of  interest  or 
importance. 

IIEA  TH  ( CHRISTOPHER),  F.  R.  G.  S., 

■^-*  Teacher  of  Operative  Surgery  in  University  College,  London. 

PRACTICAL   ANATOMY:    A   Manual   of  Dissections.     From   the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  Kbjbn, 
M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia. 
In  one  handsome  royal  12mo.  volume  of  578  pages,  with  247  illustrations.  Extra  cloth, 
$3  50  ;  leather,  $4  00.      {Lately  PubUsked.) 


Dr.  Keen,  the  American  editor  of  this  work,  in  his 
prei'ace,  siiys  :  "In  presenting  this  American  editiun 
of  'Heath's  Practical  Anatomy,'  I  feel  that  I  have 
been  instrumental  in  supplying  a  want  long  felt  for 
a  real  dissector's  manual,"  and  this  assertion  of  its 
editor  we  deem  is  fully  justified,  after  an  examina- 
bion  of  its  contents,  for  it  is  really  an  excellent  work. 
Indeed,  we  do  not  hesitate  to  say,  the  best  of  its  class 
with  which  we  are  acciuainted  ;  resembling  Wilson 
in  terse  and  clear  description,  excelling  most  of  the 
80-called  practical  anatomical  dissectors  iu  the  scope 
of  the  subject  and  practical  selected  matter.  .  .  . 
In  reading  this  work,  one  is  forcibly  impressed  with 
the  great  pains  the  author  takes  to  impress  the  sub- 
ject upon  the  mind  of  the  student.  He  is  full  of  rare 
and  pleasing  little  devices  to  aid  memory  in  main- 


taining its  hold  upon  the  slippery  slopes  of  anatomy. 
—Ht.  Louis  Med.  and  Surg.  Journal,  Mar.  10,  1871. 

It  appears  to  us  certain  that,  as  a  guide  in  dissec- 
ion,  and  as  a  work  containing  facts  ot  anatomy  in 
arief  and  easily  understood  form,  this  manual  is 
jomplete.  This  work  contains,  also,  very  perfect 
.llustrations  of  parts  which  cau  thus  be  mure  easily 
inderstood  and  studied;  in  this  respect  it  compares 
'avurably  with  works  of  much  greater  pretension. 
Such  manuals  of  anatomy  are  always  favorite  worka 
with  medical  students.  We  would  earnestly  recom- 
meud  this  one  to  their  atteation;  it  has  excellences 
which  make  it  valuable  as  a  guide  in  dissecting,  as 
well  as  in  studying  anatomy. — Bugalo  Medical  and 
Surgical  Journal,  Jan.  1871. 


'DELL AMY [E.),  F.R.G.S. 

THE  STUDENT'S  GUIDE  TO  SURGICAL  ANATOxMY:  A  Text- 

Book  for  Students  preparing  for  their  Pass  Examination.     With  engravings  on  wood.    In 
ono  handsome  royal  l^mo.  volume.     Cloth,  $2  25.      {Just  Ready.) 


■We  welcome  Mr.  Bellamy  s  work,  as  a  contribu- 
tion to  the  study  of  regional  anatomy,  of  equal  value 
to  the  student  and  the  surgeon.  It  is  wriiten  in  a 
clear  and  concise  style,  and  its  practical  suggestions 
add  largely  to  the  interest  attacliiug  to  its  leclmical 
details  — Chicago  Med.  hxamintr ,  Maich  1,  1S7-1. 

We  cordially  congratulate  Mr.  Bellamy  upon  hav- 
ing produced  it. — Mtd.  Times  and  Gaz. 


We  cannot  too  highly  recommend  it. — Student's 
Journal. 

Mr.  Bellamy  has  spared  no  pains  to  produce  a  real- 
ly reliable  student's  guide  to  surgical  anatomy — one 
which  all  candidates  for  surgical  degree^  may  c  ;U- 
suli  with  advHUtage,  and  which  posseses  much  ori 
ginal  matter  — Med.  Press  and  Circular. 


MACLISE  {JOSEPH). 

SURGICAL   ANATOMY.      By  Joseph  Maclise,  Surgeon.     In  one 

volume,  very  large  imperial  quarto;  with  68  large  and  splendid  plates,  drawn  in  the  best 
style  and  beautifully  colored,  containing  190  figures,  many  of  them  the  size  of  life;  together 
with  copious  explanatory  letter-press.  Strongly  and  handsomely  bound  in  extra  cloth. 
Price  $14  00. 

{ions  have  hitherto,  we  think,  been  given.  While 
he  operator  is  shown  every  vessel  and  nerve  where 
j.n  operation  is  contemplated,  the  exact  anatomist  is 
refreshed  oy  those  cieai  ana  Ulstinct  dissections, 
which  every  one  must  appreciate  who  has  a  particle 
of  enthusiasm.  The  English  medical  press  has  quite 
exhausted  the  words  of  praise,  in  recommending  this 
admirable  treatise. — Boston  Med.  and  Surg.  Journ, 


We  know  of  no  work  on  surgical  anatomy  which 
can  compete  with  it. — Lancet. 

The  work  of  Maclise  on  surgical  anatomy  is  of  the 
highest  value.  In  some  respects  it  is  the  best  publi- 
cation of  its  kind  we  have  seen,  and  is  worthy  of  a 
place  in  the  libiary  of  any  medical  man,  while  the 
student  could  scarcely  make  a  better  investment  than 
this. — The  Western  Journal  of  Medicine  and  Surgery. 

No  snch  lithographic  illustrations  of  surgical  re 


H 


AR  TSHORNE  [HENR Y) .  M.  D., 

Professor  of  Hygiene,  etc  ,  in  the  Univ.  ofPenna. 

HANDBOOK  OF   ANATOMY  AND   PHYSIOLOGY. 

tion,  revised.     In  one  royal  I2rao.  volume,  with  numerous  illustrations. 


Second  Edi- 

{Prepari  >ig .) 


Henry  C.  Lea's  Publications — (Physiology). 


MARSHALL   {JOHN),  F.  R.  S., 

JXL  Professor  of  Surgery  in  University  College,  London,  &c. 

OUTLINES  OF  PHYSIOLOGY,  HUMAN^  AND  COMPARATIVE. 

With  Additions  by  Fkancis  Gurnet  Smith,  M.  D.,  Professor  of  the  Institutes  of  Medi- 
cine in  the  University  of  Pennsylvania,  Ac.  With  numerous  illustrations.  In  one  large 
and  handsome  octavo  volume,  of  1026  pages,  extra  cloth,  $6  50  ;  leather,  raised  bands, 
$7  60. 


In  fact,  in  every  respect,  Mr.  Marshall  has  present- 
ed us  with  a  most  complete,  relinhle,  and  scientific 
work,  and  we  feel  that  it  is  worthy  our  warmest 
commendation. — St.  Louis  Med.  Heporter,  Jan.  1S69. 

We  doubt  if  there  is  in  the  English  language  any 
compend  of  physiology  more  useful  to  the  student 
thitn  this  work. — St.  LovAs  3Ied.  and  Surg.  Journal, 
Jan.  1S69. 

It  quite  fulfils,  in  our  opinion,  the  author's  de'^ign 
of  making  it  truly  «f??4effliro'/ian  nits  character — which 
Is.  perhaps,  the  highest  commendation  that  can  be 
asked. — Am.  Journ.  Med.  Sciences,  Jan.  1&69. 

We  may  now  congratulate  him  on  having  com- 
pleted the  latest  as  well  as  the  best  summary  of  mod- 
ern physiolugical  science,  both  tiuman  and  coiupara 


tive,  with  which  we  are  acquainted.  To  speak  oJ 
this  work  in  the  terms  ordinarily  used  on  such  occa- 
sions would  not  be  agreeable  to  ourselves,  and  would 
fail  to  do  justice  lo  its  author.  To  write  such  a  book 
requires  a  varied  and  wide  range  of  knowledge,  con 
siderable  power  of  analysis,  correct  judgment,  skill 
in  ariangi-ment.  and  conscientious  spirit. — Londori 
Lancet,  Feb.  22,  1S6S. 

There  are  few,  if  any,  more  accomplished  anatomists 
and  physiologists  than  the  distinguished  professor  of 
surgery  at  University  College  ;  and  ht  has  long  en 
joyed  the  highest  reputation  as  a  teachei  of  physiol- 
ogy, possessing  remarkable  powers  of  cleai  exposition 
and  graphic  illustration.  We  have  rareli  the  plea- 
sure of  beiug  able  to  recommend  a  text-bool  so  unre- 
servedly as  this. — British  Med.  Journal,  Jar   25,1868. 


rtARPENTER   [WILLIAM  B.),  M.D.,  F.R.S., 

V/  Examiner  in  Phy.nology  and  Comparative  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HITMAN  PHYSIOLOGY;  with  their  chief  appli- 
cations to  Psychology,  Pathology,  Therapeutics,  Hygiene  and  Forensic  Medicine.  A  new 
American  from  the  last  and  revised  London  edition.  With  nearly  three  hundred  illustrations 
Edited,  with  additions,  by  Fkancis  Gurnet  Smith,  M.  D.,  Professor  of  the  Institutes  of 
Medicine  in  the  University  of  Pennsylvania,  &c.  In  one  very  large  and  beautiful  octavo 
volume,  of  about  90U  large  pages,  handsomely  printed ;  extra  cloth,  $5  50;  leather,  raised 
bands,  $6  50. 
With  Dr.  Smith,  we  confidently  believe  "that  the 

present  will  more  ihan  sustain  the  enviable  reputa- 
tion already  attained  by  former   editions,  of  being 

one  of  the  fullest  and  most  complete  treatises  on  the 

?ti  bject  in  the  English  language."     We  know  of  none 

from  the  pages  of  which  a  satisfactory  knowledge  of 

the  pliysislogy  of  the  human  organi^.in  can  be  as  well 

obtained,  none  better  adapted  for  the  use  of  such  as 

take  up  t  he  study  of  physiology  in  its  reference  to 

the  institales  and  practice  of  medicine. — Am.  Jour. 

Med.  Sciences. 


We  doubt  not  it  is  destined  to  retain  a  strong  hold 
on  public  favor,  and  remain  the  favorite  text-book  in 
our  colleges. — Virginia  Medical  Journal. 

The  above  is  the  title  of  what  is  emphatically  tht 
great  work  on  physiology ;  and  we  are  conscious  that 
it  would  be  a  useless  effort  to  attempt  to  add  any- 
thing to  the  reputation  of  this  invaluable  work,  and 
can  only  say  to  all  with  whom  our  opinion  has  any 
influence,  that  it  is  our  authority. — Atlanta  Med. 
Journal. 


jDT  THE  SAME  AUTHOR. 

PRINCIPLES  OF  COMPARATIYE  PHYSIOLOGY.  New  Ameri- 
can, from  the  Fourth  and  Revised  London  Edition.  In  one  large  and  handsome  octavo 
volume,  with  over  three  hundred  beautiful  illustrations      Pp.752.    Extra  cloth,  $5  00. 

As  a  complete  and  condensed  treatise  on  its  extended  and  important  subject,  this  work  becomes 
a  necessity  to  students  of  natural  science,  while  the  very  low  price  at  which  it  is  offered  places  it 
within  the  reach  of  all. 


17'IRKES  [WILLIAM  SENHOUSE),  M.D. 

A  MANUAL  OF  PHYSIOLOGY.     Edited  by  TV.  Morrant  Baker, 

M.D.,  F.R.C.S.      A  new  American  from  the  eighth  and  improved  London  edition.     With 
about  two  hundred  and  fitly  illu.strations.     In  one  large  and  handsome  royal  12mo.  vol- 
ume.     Cloth,  $3  26;   leather,  %'^   75.      [Nov.-  Ready .) 
Kirkes'  Physiology  hns  long  been  known  as  a  concise  and  exceedingly  convenient  text-book, 
presenting  within  a  narrow  compass  all  that  is  important  for   the  student.     The  rapidity  with 
which  successive  editions  have  followed  each  other  in  England  has  enabled  the  editor  to  keep  it 
thoroughly  on  a  level  with  the  changes  and  new  discoveries  made  in  the  science,  and  the  eighth 
edition,  of  which  the  present  is  a  reprint,  has  appeared  so  recently  that  it  may  be  regarded  as 
the  latest  accessible  exposition  of  the  subject. 


On  the  whole,  there  is  very  little  in  the  book 
which  either  tlie  student  or  practitioner  will  notfind 
of  practical  value  and  consistent  with  our  present 
knowledge  of  this  rapidly  cUaugiBg  tcience  ;  and  we 
h<ve  no  hesitation  in  exprei  sing  our  opinion  that 
this  eighth  edition  is  one  of  the  best  handbooks  on 
physiology  which  we  have  in  uur  language. — N.  Y. 
Med.  Record,  April  \o,  lS7a. 

This  volume  might  well  be  used  to  replace  many 
of  the  physiological  text-books  in  use  iu  this  coun- 
try. It  represents  more  accurately  than  the  works 
of  Dalton  or  Flint,  the  present  state  of  our  knowl- 
edge of  most  physiological  questions,  while  it  is 
mach  less  bulky  and  far  more  readable  than  the  lar- 


ger text-books  of  Carpenter  or  Marshall.  The  book 
is  admirably  adapted  to  be  placed  in  the  hands  of 
studen,s. — Boston  Med.  and  Surg.  Journ.,  April  10, 
1S7:1 

In  its  enlarged  form  it  is,  in  our  opinion,  still  the 
best  book  on  physiology,  most  usefal  to  the  student. 
—Phila.  Med.  Tinie.'<,  Aug.  30,  1S73. 

This  is  undoubtedly  the  best  work  for  students  of 
physiology  extant. — Cincinnati  Mid.  News,  Sept.  '73 

It  more  nearly  represents  the  present  condition  of 
physiology  than  any  other  textbook  on  the  subject.— 
IMroit  a'tv.  of  Med.  PUarm.,  Xov.  1S73. 


Henry  C.  Lea's  Publications — {Physiology). 


9 


fi ALTON  {J.  C),  M.  D., 

-*--'  Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  &c. 

A  TREATISE  0^  HUMAN  PHYSIOLOGY.    Designed  for  the  use 

of  Students  and  Practitioners  of  Medicine.     Fifth  edition,  revised,  with  nearly  three  hun 
dred  illustrations  on  wood.     In  one  very  beautiful  octavo  volume,  of  over  700  pages,  extia 
cloth,  $5  25  ;  leather,  $6  25.     {Lately  Issued.) 

Preface  to  the  Fifth  Edition. 

In  preparing  the  present  edition  of  this  work,  the  general  plan  and  arrangement  of  the  previous 
editions  have  been  retained,  so  far  as  they  have  been  found  useful  and  adapted  to  the  purposes  of 
a  text-book  for  students  of  medicine.  The  incessant  advance  of  all  the  natural  and  physical 
sciences,  never  more  active  than  within  the  last  five  years,  has  furnished  many  valuable  aids  to 
the  special  investigations  of  the  physiologist;  and  the  progress  of  physiological  research,  during 
the  same  period,  has  required  a  careful  revision  of  the  entire  work,  and  the  modification  or  re- 
arrangement of  many  of  its  parts.  At  this  day,  nothing  is  regarded  as  of  any  value  in  natural 
science  which  is  not  based  upon  direct  and  intelligible  observation  or  experiment;  and,  accord- 
ingly, the  discussion  of  doubtful  or  theoretical  questions  has  been  avoided,  as  a  general  rule,  in 
the  present  volume,  while  new  facts,  from  whatever  source,  if  fully  established,  have  been  added 
and  incorporated  with  the  results  of  previous  investigation.  A  number  of  new  illustrations  have 
been  introduced,  and  a  few  of  the  older  ones,  which  seemed  to  be  no  longer  useful,  have  been 
omitted.  In  all  the  changes  and  additions  thus  made,  it  has  been  the  aim  of  the  writer  to  make  the 
book,  in  its  present  form,  a  faithful  exponent  of  the  actual  conditions  of  physiological  science. 
New  York,  October,  1S71. 

In  this,  the  standard  text-book  on  Physiology,  all  that  is  needed  to  maintain  the  favor  with  which 
it  is  regarded  by  the  profession,  is  the  author's  assurance  that  it  has  been  thoroughly  revised  and 
brought  up  to  a  level  with  the  advanced  science  of  the  day.  To  accomplish  this  has  required 
some  enlargement  of  the  work,  but  no  advance  has  been  made  in  the  price. 


The  fifth  edition  of  this  truly  valuable  work  on 
Human  Pliysiology  comes  to  uswitli  many  valuable 
improvemeuts  and  additions.  As  a  text-book  of 
physiology  tlie  work  of  Prof.  Dalton  Hhs  long  been 
well  kno  wa  as  one  of  the  best  which  could  be  placed 
in  the  hands  of  student  or  practitioner.  Prof.  Dalton 
has,  in  the  several  editions  of  his  work  heretofore 
published,  labored  to  keep  step  with  the  advancement 
in  science,  and  the  last  edition  shows  by  its  improve- 
ments on  former  ones  that  he  is  determined  to  main- 
tain the  high  standard  of  his  work.  We  predict  for 
the  present  edition  increased  favor,  though  this  work 
kas  long  been  the  favorite  standard. — Buffalo  Med. 
and  Surg.  Journal,  April,  1S72. 

An  extended  notice  of  a  work  so  generally  and  fa- 
vorably known  as  this  is  unnecessary.  It  is  justly 
regarded  as  one  of  the  most  valuable  text-book.s  on 
the  subject  in  the  English  language. — St.  Lovdi  Med. 
Archives,  May,  IS'72. 

We  know  no  treatise  in  physiology  so  clear,  com- 
plete, well  assimilated,  and  perfectly  digested,  as 
Dalton's.  He  never  writes  cloudily  or  dubiously,  or 
in  mere  quotation.  He  assimilates  all  his  material, 
and  from  it  constructs  a  homogeneous  transparent 
argument,  which  is  always  houestaud  well  informed, 
and  hides  neither  truth,  ignorance,  nor  doubt,  so  far 
as  either  belongs  to  the  subject  in  hand — Brit.  Med. 
Journal,  March  23,  1672. 


Dr.  Dalton's  treatise  is  well  known,  and  by  many 
highly  esteemed  in  thiscounlry.  It  is,  indeed,  a  good 
elementary  treatise  on  the  subject  it  professes  to 
teach,  and  may  safely  be  put  into  the  hands  of  Eng- 
lish students.  It  has  one  great  merit — it  is  clear,  and 
on  the  whole,  admirably  illustrated.  The  part  we 
have  always  esteemed  most  highly  is  that  relating 
to  Embryology.  The  diagrams  given  of  the  various 
stages  of  development  give  a  clearer  view  of  the  sub- 
ject than  do  those  in  general  use  in  this  country  ;  aud 
the  text  may  be  said  to  be,  upon  the  whole,  equally 
clear. — London  Med.  Times  and  Gazette,  March  23 
1872. 

Dalton's  Physiology  is  already,  and  deservedly, 
the  favorite  text-book  of  the  majority  of  American 
medical  students.  Treating  a  most  interesting  de- 
partment of  science  in  his  own  peculiarly  lively  and 
fascinating  style,  Dr.  Dalton  carries  his  reader  along 
without  effort,  aud  at  the  same  time  impresses  upon 
his  mind  the  truths  taught  much  more  sucoes,-ifully 
than  if  they  were  buried  beneath  a  multitude  of 
words. — Kansas  Oity  Med.  Journal,  April,  1S72. 

Professor  Dalton  is  regarded  justly  as  the  authority 
ia  this  country  on  physiological  subjects,  and  the 
fifth  edition  of  his  valuable  work  fully  j  ustifies  the 
exalted  opinion  the  medical  world  has  of  his  labors. 
This  last editiouisgreatly enlarged. —  Virginia  Clin- 
ical Record,  April,  1872. 


D 


UNGLISON  [ROBLEY),  M.D., 

Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

HUMAN  PHYSIOLOGY.     Eighth  edition.     Thoroughly  revised  and 

extensively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.     In  two 
large  and  handsomely  printed  octavo  volumes  of  about  1500  pages,  extra  cloth.     $7  GO. 


L 


EEMANN  {G.  G.).    , 
PHYSIOLOGICAL  CHEMISTRY.    Translated  from  the  second  edi- 

tion  by  Georse  E.  Day,  M.  D.,  F.  R.  S.,  Ac,  edited  by  R.  E.  Rogers,  M.  D.,  Professor  of 
Chemistry  in  the  Medical  Department  of  the  University  of  Penn.sylvania,  with  illustrations 
selected  from  Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  plates.  Com- 
plete in  two  large  and  handsome  octavo  volumes,  containing  1200  pages,  with  nearly  two 
hundred  illustrations,  extra  cloth.     $6  00. 


J>T  THE  SAME  AUTHOR. 

MANUAL  OF  CHEMICAL  PHYSIOLOGY. 


Translated  from  the 


German,  with  Notes  and  Additions,  by  J  Cheston  Morris,  M.  D.,  with  an  Introductory 
Essay  on  Vital  Force,  by  Professor  Samuel  Jackson,  M.  D.,  of  the  University  of  Pennsyl- 
vania.  With  illustrations  on  wood.  In  one  veryhardsome  octavo  volume  of  336  pages, 
extra  cioth.     $2  25. 


10 


Henry  C.  Lea's  Publications — (Chemistry). 


ATTFIELD  {JOHN),  Ph.D., 

Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Oreaf  Britain,  *c. 

CHEMISTRY,    GENERAL,  MEDICAL,  AND  PHARMACEUTICAL; 

includi-ng  the  Cbemiptry  of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.  Fifth  Edition,  revi.^ed 
by  the  author.  In  one  handsome  royal  12mo.  volume  ;  cloth,  $2  75  ;  leather,  $-3  25. 
(Just  Issued.) 


"We  commend  tte  work  'heartily  as  one  of  the  best 
text-liooks  extant  for  the  medical  student. — Detroit 
Sev.  of  Med.  and  Pharm.,  Feb.  1872. 

The  be.«t  work  of  the  kind  in  the  English  ' 
iV.  T.  Psychological  Journal,  Jan.  1S72. 

The  work  is  constrncted  with  direct  reference  to 
the  wants  of  medical  and  pharmaceutical  stndent-s; 
and,  althongb  an  Englisb  work,  the  points  of  differ- 
ence between  the  British  and  United  States  Pharma- 
copceias  are  indicated,  making  it  as  useful  here  as  in 
England.  Altogether,  the  hook  is  one  we  can  heart- 
ily recommend  to  practitioners  as  well  as  students. 
—N.  r.  Med.  Journal,  Dec.  1871. 

It  differs  from  other  text-books  in  the  following 
particulars:  first,  in  the  exclusion  of  matter  relating 
to  compounds  which,  at  present,  are  only  of  interest 
to  the  scientific  chemist ;  secondly,  in  coniainin?  the 
chemistry  of  every  substance  recognized  officially  or 
in  general,  as  a  remedial  agent.  It  will  he  found  a 
most  valnable  book  for  pupils,  a.'sistants.  and  others 
engaged  in  medicine  and  pharmacy,  and  we  heartily 
commend  it  to  our  readers. — Canada  Lancet,  Oct. 
1871. 

When  the  original  English  edition  of  this  work  was 


published,  we  had  occasion  to  express  our  high  ap- 
preciation of  its  worth,  and  also  to  review,  in  con- 
siderable detail,  the  main  features  of  the  hook.  As 
the  arrangement  of  subjects,  and  the  main  part  of 
the  text  of  the  present  edition  are  similar  to  the  for- 
mer publication,  it  will  be  needless  for  us  to  go  over 
the  ground  a  second  time;  we  may.  however,  call  at- 
tention to  a  marked  advantage  possessed  by  the  Ame- 
rican work — we  allude  to  the  introduction  of  the 
chemistry  of  the  preparations  of  the  United  States 
Pharmacopceia.  as  well  as  that  relating  to  the  British 
authority.  —  Canadian  Pharrnnceutieal  Journal, 
Nov.  1871. 

Chemistry  has  borne  the  name  of  being  a  hard  sub- 
ject to  master  by  the  student  of  medicine,  and 
chiefly  because  so  much  of  it  consists  of  compounds 
only  of  interest  to  the  scientific  chemist ;  in  this  work 
such  portions  are  modified  or  altogether  left  out,  and 
in  the  arrangement  of  the  subject  matter  of  the  work, 
practical  utility  is  sought  after,  and  we  think  fully 
attained  We  commend  it  for  its  clearness  and  order 
to  both  teacher  and  pupil. — Oregon  Med.  and  Surg. 
Reporter,  Oct.  1871. 


JDLOXAM  (C.  L.), 

J-^  Professor  of  Chemistry  in  King's  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.     From  the  Second  Lon- 

don  Edition.     In  one  very  hand.=ome  octavo  volume,  of  700  pages,  with  about  300  illustra- 
tions.    Cloth,  $4  50;  leather,  $5  50.      (Now  Ready.) 

It  has  been  the  author's  endeavor  to  produce  a  Treatise  on  Chemistry  sufficiently  comprehen- 
sive for  tho.se  studying  the  science  as  a  branch  of  general  education,  and  one  which  a  student 
may  use  with  advantage  in  pursuing  his  chemical  studies  atone  of  the  colleges  or  medical  school.*. 
The  special  attention  devoted  to  Metallurgy  and  some  other  branches  of  Applied  Chemistry  rendei-s 
the  work  especially  useful  to  those  who  are  being  educated  for  employment  in  manufacture. 

It  would  be  difficult  for  a  practical  chemist  and 
tparher  to  find  any  material  fault  with  this  most  ad- 
mirable treatise.  The  author  has  given  us  almost  a 
cyclopedia  within  the  limits  of  a  convenient  volume, 
and  has  done  so  without  penning  the  useless  para- 
graphs too  commonly  making  up  a  great  part  of  the 
bulk  of  many  cumbrous  wurks.  The  progressive  sci- 
entistis  not  disappointed  when  helonks  for  the  record 
of  new  and  valnable  processes  and  discoveries,  while 
the  cautious  conservative  does  not  find  its  pages  mo- 
nopolized by  uncertain  theories  and  speculations.  A 
peculiar  point  of  excellence  is  the  crystallized  form  of 
expression  in  which  great  truths  are  expressed  in 


very  short  paragraphs  One  is  surprised  at  the  brief 
space  allotted  to  an  important  topic,  and  yet,  afrer 
reading  it,  he  feels  that  little,  if  any  more,  should 
have  been  said.  Altogether,  it  is  seldom  you  see  a 
text-book  so  nearly  faultless.— C'iweiwraa^i  Lancet, 
iVov.  1873. 

Prjfessor  Bloxam  has  given  ns  a  most  excellent 
and  u.seful  practical  trettise.  His  666  pages  are 
crowded  with  facts  and  experiments,  nearly  all  well 
chosen,  and  manv  Quite  new^,  even  to  scientific  men. 
.  .  .  It  is  astonishinghow  much  iaformationhe  often 
conveys  in  a  few  paragraphs.  We  might  quote  fifty 
instances  of  this. — Chtruical  News. 


0 


DLTNG  {WILLIAM), 

Lecturer  on  Chemistry  at  St.  Bartholomew's  So.fpitaJ,  iVc. 

A  COURSE  OF  PRACTICAL  CHEMISTRY,  arranged  for  the  Use 

of  Medical  Students.    With  Illustrations.    From  the  Fourth  and  Revised  London  Edition. 
In  on©  neat  royal  12mo.  volume,  extra  cloth.     $2.     (Lately  Issued.) 


/CALLOWAY  (ROBERT),  F.C.S., 

ty  Prof,  of  Applied  Ohernistry  in  the  Royal  College  of  Science  for  Ireland,  &c. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.     From  the  Fifth  Lon- 

don  Edition.    In  one  neat  royal  12mo.  volume,  with  illustrations  ;  extra  cloth,  $2  50.     (Just 
Issued.) 
The  success  which  has  carried  this  work  through  repeated  editions  in  England,  and  its  adoption 
as  a  text-book  in  several  of  the  leading  in.stitutions  in  this  country,  show  that  the  author  has  suc- 
ceeded in  the  endeavor  to  produce  a  sound  pructical  manual  and  book  of  reference  for  the  che- 
mical student. 

Prof  Galloway's  books  are  deservedly  io  bigh  i  We  regard  this  volnnie  as  a  valnable  addition  to 
esteem,  and  this  American  reprint  of  the  fifth  edition  the  chemical  text-books,  and  as  panictilarly  calcn- 
(1863)  of  his  Manual  of  Qualitative  Analysis,  will  be  |  lated  to  instruct  the  student  in  aralylioal  re.searches 
acceptable  to  many  American  students  to  whom  the  of  the  inorganic  compKunds,  the  iinportani  vegetable 
English  edition  is  not  accessible. — A-m.  Jour,  of  Set-  j  acids,  and  of  cnmpounds  and  Viirious  recrelions  and 
«74ce  and  Arts,  Sept.  1872.  i  ►-xcrelions  of  animal  origin. — Am.  Jotxrn.  o/  PlionA., 

I  Sept.  1872. 


Henry  C.  Lea's  Publications — (Chemistry).  11 

/^HANDLER  {CHARLES  F.),      and     nUANDLER  [WILLIAM  H.), 

\y  Prof .  of  Chemistry  in  the  N.  ¥.  Coll.  0/  ^  Pmf  nf  O'lemistry  in  the  Lehigh 

Pharrnory  University. 

THE    AMERICAN    CHEMIST:    A  Monthly  Journal  of  Theoretical, 

Analytical,  and  Technical  Chemistry.  Each  number  averaging  forty  large  double  col- 
umned pages  of  reading  matter.    Price  $5  per  annum  in  advance.    Single  numbers,  50  cts. 

D:;^  Specimen  numbers  to  parties  proposing  to  subscribe  will  be  sent  to  any  address  on  receipt 
of  25  cents. 

*^*  Subscriptions  can  begin  with  any  number. 

The  r.apid  growth  of  the  Science  of  Chemistry  and  its  infinite  applications  to  other  sciences 
and  art.«  render  a  journal  specially  devoted  to  the  subject  a  necessity  to  those  whose  pursuits 
require  familiarity  with  the  details  of  the  science.  It  has  been  the  aim  of  the  conductors  of  "The 
American  Chemist"  to  supply  this  want  in  its  broadest  sense,  and  the  reputation  which  the 
periodical  has  already  attained  is  a  sufficient  evidence  of  the  zeal  and  ability  with  which  they 
have  discharged  their  tnsk. 

Assisted  by  an  nble  body  of  coUabor.ators,  their  aim  is  to  present,  within  a  moderate  compass, 
an  abstract  of  the  progress  of  the  science  in  all  its  departments,  scientific  and  technical.  Import- 
ant original  communications  and  selected  papers  are  given  in  full,  and  the  standing  of  the  "  Chem- 
ist" is  such  as  to  secure  the  eontributinns  of  le  wlin^^  in  -  in  all  portions  of  the  country.  Besides 
this,  over  one  hundred  journals  and  transactions  of  learned  societies  in  America,  Great  Britain, 
France,  Belgium,  Italy,  Russia,  and  Germany  are  carefully  scrutinized,  and  whatever  they  offer 
of  interest  is  condensed  and  presented  to  the  reader.  lu  this  work,  which  forms  a  special  feature 
of  the  "Chemist,"  the  editors  have  the  assistance  of  M.  Alsberg,  Ph.D.,  Prof.  G.  F.  Barker,  T. 
M.  Blossom,  E.M.,  H.  C.  Bolton,  Ph.D.,  Prof.  T.  Egleston,  E.M  ,  H.  Endemana,  Ph.D.,  Prof.  C. 
A.  Goessmann,  Ph.D.,S.  A.  Goldschmidt,  A.M.,  E.M.,  E.  J.  Hallock.  Prof.  C.  A.  Joy,  Ph.D., 
J.  P.  Kimball,  Ph.D.,  0.  G.  Mason,  H.  Newton,  E.M.,  Prof.  Frederick  Prime,  Jr.,  Prof.  Paul 
Schweitzer,  Ph.D  ,  Waldron  Shapleigh,  Romyn  Hitchcock,  and  BIwyn  Waller,  E.M.  From  the 
thoroughness  and  completeness  with  which  this  department  is  conducted,  it  is  believed  that  no 
periodical  in  either  hemisphere  more  faithfully  reflects  the  progress  of  the  scieace,  or  presents  a 
larger  or  more  carefully  garnered  store  of  information  to  its  readers. 

pOWNES  [GEORGE),  Ph.  D. 

A  MANUAL  OF  ELEMENTARY  CHEMISTRY;   Theoretical  and 

Practical.  With  one  hundred  and  ninety-seven  illustrations.  A  new  American,  from  the 
tenth  and  revised  London  edition.  Edited  by  Robert  Bridges,  M.  D.  In  one  large 
royal  I2mo.  volume,  of  about  850  pp  ,  extra  cloth,  .■J2  75  ;  leather,  .-53  25.    {Lately  Issued.) 

This  -work,  is  so  well  known  that  it  .seem.s  almost  )ther  work  that  has  greaier  claims  oa  the  physiciao, 
saperfluous  for  us  to  speak  about  It.  It  has  been  a  pharmaceutist,  or  student,  than  this.  We  cheerfully 
fovorite  text-book  with  medical  students  for  years,  recommend  it  as  the  best  text-book  on  elementary 
and  its  popularity  has  in  no  respect  diminished.  •  chemistry,  and  bespeak  for  it  the  careful  attentioa 
Whenever  we  have  been  consulted  by  medical  stu-  of  students  of  pharmacy. — Chicago  Pharmacist,  A.ag, 
dents,  as  ha.s  frequently  occurred,  what  treatise  on  ,  1869. 

ehemistry  they  t-hunld  procure,  we  have  always  re-        „        .  ,.,.  ,  .  ,  ,       .         ,  ,.,_:, 

eomraendid  Fownes',  for  we  regarded  it  as  the  best.  ,  ^e'e  is  a  new  edition  which  has  been  long  watche^d 
TJiere  is  no  work  that  combines  so  manv  excellen-  ^-^^  ^^  eager  teachers  of  chemistry.  In  Us  new  garb 
ces.  It  is  of  convenient  size,  not  prolix,  of  plain  and  under  the  editorship  of  Mr.  Watt.s,  it  has  resumed 
perspicnous  diction,  contains  all  the  most  recent  V'i'.^'^  "^l^^S -^^ ,^l^  "^Z^^  r ''"''f  f^i"  ^^^^-^'"'^^■- 
diseovenes,  and  is  of  moderate  ptice. -CineinnatiJ'^^^'^'^  Medical  Gazette,  Jan.  1,  1869 
Med.  Repertory,  Aug.  1869.  |      ^  ^-^n  continue,  as  heretofore,  to  hold  the  Irst  rank 

Large  additions  have  been  made,  esppcially  in  the  is  a  text-book  for  students  of  medicine. — Chicago 
department  of  organic  chemistry,  and  we  know  of  no     Med.  Examiner,  Aug.  1869. 


TU'OIILER  AND  FITTIG. 

^^    OUTLINES  OF  ORGANIC  CHEMISTRY.     Translated  with  Ad- 
ditions from  the  Eighth  German   Edition.     By  Iea  Rejesen,  M.D.,  Ph.D.,  Professor  of 
Chemistry  and  Physics  in  Williams  College,  Mass.     In  one  handsome  volume,  royal  I2mo. 
of  650  pp.  extra  cloth,  $.3.      {Just  Issued.) 
As  the  numerous  editions  of  the  original  attest,  this  work  is  the  leading  text-book  .and  standard 
authority  throughout  Germany  on  its  important  and  intricate  subject — a  position  won  for  it  by 
the  clearness  and  conciseness  which  are  its  distinguishing  characteristics.     The  translation  has 
been  executed  with  the  approbation  of  Profs.  Wdhler  and  Fittig,  and  numerous  additions  and 
alterations  have  been  introduced,  so  as  to  reader  it  in  every  respect  on  a  level  with  the  most 
axivanced  condition  of  the  science. 

no  WMAN  [JOHN  E.) ,  M.  D. 
PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.    Edited 

by  C.  L.   Bloxam,  Professor  of  Practical  Chemistry  in  King's  College,  London.      Sixth 
American,  from  the  fourth  and  revised  English  Edition.     In  one  neat  volume,  royal  12mo., 
pp.  351,  with  numerous  illustrations,  extra  cloth.     $2  25. 
_gF  THE  SAME  AUTHOR.     (Noio  Rea-y  )  

INTRODUCTION   TO    PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.     Sixth  American,  from  the  sixth  and  revised  London  edition.    With  numer- 
otis  illugtrations.     In  one  neat  vol.,  royal  12mo.,  extra  cloth.     S2  25. 

KBTAPP'S  TECHNOLOGY;  or  Chemistry  Applied  to  I      very  handsome  octavo   volumes,  with.  600   wood 
tbfi   ,4.rts,   and  to  Manufactures.     With  American  I     engravings,  extra  cloth,  $6  00. 
addiii  >n6,  by  Prof.  Waltee  E.  Johsson.    la  two  I 


12       Henry  C.  Lea's  Publications — (Mat.  Med.  and  Therapeutics). 


pARRlSH  {EDWARD), 

Late  Professor  of  Materia  Mediea  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.     Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.     With  many  Formulae  and 
Prescriptions.     Fourth  Edition,  thoroughly  revised,  by  Thomas  S.   Wiegand.      In  ore 
handsome  octavo  volume  of  977  pages,  with  280  illusti-ations ;  cloth,  $5  60;  leather,  $6  50. 
ilSow  Ready.) 
The  delay  in  ihe  appearance  of  the  new  U.  S.  Pharmacopoeia,  and  the  siidden  death  of  the  au- 
thor, have  postponed  the  preparation  of  this  new  edition  beyond  the  period  expected.     The  notes 
and  memoranda  left  by  Mr.  Parrish  have  been  placed  in  the  hands  of  the  editor,  Mr.  Wiegnnd, 
who  has  labored  assiduously  to  embody  in  the  work  all  the  improvements  of  pharmaceutical  sci- 
ence which  have  been  introduced  during  ;be  last  ten  years.     It  is  therefore  hoped  that  the  new 
edition  will  fully  maintain  the  reputation  which  the  volume  has  heretofore  enjoyed  as  a  standard 
text-book  and  work  of  reference  for  all  engaged  in  the  preparation  and  dispensing  of  medicines. 
We  have  examined  this  large  volume  with  a  good    not  wish  it  to  be  understood  as  very  extravagant 
deal  of  care,  and  find  that  the  anthor  has  completely  I  praise.     In  truth,  it  is  not  so  much  the  best  as  the 
exhausted  the  subject  upon  which  he  treats  ;  a  more    only  book. — The  London  Chemical  News. 


complete  work,  we  think,  it  would  be  impossible  to 
find.  To  the  student  of  pharmacy  the  work  is  indis- 
pensable ;  indeed,  so  far  as  we  know,  it  is  the  only  one 
of  its  kind  in  existence,  and  even  to  the  physician  or 
medical  student  who  can  spare  five  dollars  to  pur- 
chase it,  we  feel  sure  the  practical  information  he 
will  obtain  will  more  than  compensate  him  for  the 
outlay. — Canada  Med.  Journal,  Nov.  1864. 

The  medical  student  and  the  practising  physician 
will  find  the  volume  of  inestimable  worth  for  study 
and  reference. — San  Francisco  Med.  Press,  July, 
1864. 

When  we  say  that  this,  book  is  in  some  respects 
the  best  which  has  been  published  on  the  subject  in 
the  English  language  for  a  great  many  years,  we  do 


An  attempt  to  furnish  anything  like  an  analysis  ol 
Parrish's  very  valuable  and  elaborate  Treatise  on 
Practical  Pharmacy  would  require  more  space  thar, 
<ve  have  at  our  disposal.  This,  however,  is  not  so 
much  a  matter  of  regret,  inasmuch  a«  it  would  be 
difficult  to  think  of  any  point,  however  minute  and 
apparently  trivial,  connected  with  the  manipulatioa 
if  pharmacemic  substances  or  appliances  which  has 
not  been  clearly  and  carefully  discussed  in  this  vol- 
ume. Want  of  space  prevents  our  enlarging  further 
on  this  valuable  work,  and  we  must  conclude  by  » 
simple  expression  of  our  hearty  appreciation  of  its 
merits. — DubWi  Quarterly  Jour,  of  Medical  Science, 
August,  1864. 


OTILLE  {ALFRED),  M.D., 

A3  Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History 

Fourth  edition,  revised  and  enlarged.    In  two  large  and  handsome  8vo.  vols.    (Priparivg.) 

Dr.  Stille's  splendid  work  on  therapeutics  and  ma-  ,  abroad  us  reputation  as  a  standard  treatiseou  lUatoi 


teria  mediea. — London  Med.  Times,  April  8,  1865 

Dr.  Still6  stands  to-day  one  of  the  best  and  most 
honored  representatives  at  home  and  abroad,  of  Ame- 
rican medicine ;  and  these  volumes,  a  library  in  them- 
selves, a  treasure-house  for  every  studious  physician, 
assure  his  fame  even  had  he  done  nothing  more. — The 
Western  Journal  of  Medicine,  Dec.  1868. 

We  regard  this  work  as  the  best  one  on  Materia 
Mediea  in  the  English  language,  and  as  such  it  de- 
serves the  favor  it  has  received. — A'm.  Journ.  Medi- 
cal Sciences,  July  1868. 

We  need  not  dwell  on  the  merits  of  the  third  edition 
of  this  magnificently  conceived  work.  It  is  the  work 
on  Materia  Mediea,  in  which  Therapeutics  are  prima- 
rily considered — the  mere  natural  history  of  drugs 
being  briefly  disposed  of.  To  medical  practitioners 
this  is  a  very  valuable  conception.  It  is  wonderful 
how  much  of  the  riclies  of  the  literature  of  Materia 
Mediea  has  been  condensed  into  this  book.  The  refer- 
ences alone  would  make  it  worth  possessing.  But  it 
is  not  a  mere  compilation.  The  writer  exercises  a 
good  judgment  of  his  own  on  the  great  doctrines  and 
points  of  Therapeutics  For  purposes  of  practice. 
Stmt's  book  is  almost  unique  as  a  repertory  of  in- 
formation, empirical  and  scientific,  on  the  actions  and 
uses  of  medicines. — London  Lancet,  Oct.  31,  1868. 

Through  the  former  editions,  the  professional  world 
Is  well  acquainted  with  this  work.      At  home  and 


Mediea  is  securely  established.  It  is  second  to  no 
work  on  the  subject  in  the  English  tongue,  and,  in- 
deed, is  decidedly  superior,  in  some  respects,  to  any 
other. — Pacific  Med.  and  Surg  Journal,  July,  1868. 

Stmt's  Therapeutics  is  incomparably  the  best  work 
on  the  subject.— iV.  Y.  Med.  Gazette,  Sept.  26,  1868. 

Dr.  Still6's  work  is  becoming  the  best  known  of  any 
of  our  treatises  on  Materia  Mediea.  .  .  .  One  of  the 
most  valuable  works  in  the  language  on  the  subject* 
of  which  it  treats.— iV.  T.  Med.  Jottrnn.l,  Oct.  1S68. 

The  rapid  exhaustion  of  two  editions  of  Prof.  Still6'» 
scholarly  wurk,  and  the  consequent  necessity  for  a 
third  edition,  is  suflicient  evidence  of  the  high  esti- 
mate placed  upon  it  by  the  profession.  It  is  no  exag- 
geration to  say  that  there  is  no  superior  work  upon 
the  subject  in  the  English  language.  The  present 
edition  is  fully  up  to  the  most  recent  advance  in  the 
science  and  art  of  therapeutics. — Leavenworth  Medi- 
cal Herald,  Aug.  1868. 

The  work  of  Prof.  Still6  has  rapidly  taken  a  high 
place  in  professional  esteem,  and  to  say  that  a  third 
edition  is  demanded  and  now  appears  before  us,  suffi- 
ciently attests  the  firm  position  this  treatise  has  made 
for  itself.  As  a  work  of  great  research,  and  scholar- 
ship, it  is  safe  to  say  we  have  nothing  superior.  It  in 
exceedingly  full,  and  the  busy  practitioner  will  find 
ample  suggestions  upon  almost  every  important  point 
of  therapeutics. — Cincinnati  Lancet,  Aug.  1S68. 


jy  ERE  IRA  {JON A  THAN),  M.D.,  F.  R.  S.  and  L.  S. 

MATERIA   MEDICA   AND  THERAPEUTICS;    being  an  Abridg- 

ment  of  the  late  Dr.  Pereira's  Elements  of  Materia  Mediea,  arranged  in  conformity  with 
the  British  Pharmacopceia,  and  adopted  to  the  use  of  Medical  Practitioners,  Chemists  and 
Druggists,  Medical  and  Ph.h-maceutieal  Students,  &c.     By   P.   J.   Parre,  M.P  ,   Senior 
Physician  to  St.  Bartholomew's  Hospital,  and  London  Editor  of  the  British  Pharmacopoeia  ; 
assisted  by  Robert  Bentley,  M.R.C.S.,  Professor  of  Materia  Mediea  and  Botany  to  the 
Pharmaceutical  Society  of  Great  Britain;   and  by  Robrrt  Warington,  F.R.S.,  Chemical 
Operator  to  the  Society  of  Apothecaries.     With  numerous  additions  and  references  to  the 
United  States  Pharmacopoeia,  by  Horatio  C.  Wood,  M.D.,   Professor  of  Botany  in  the 
University  of  Pennsylvania.       In  one  large  and  himdsome  octavo  volume  of  1040  closely 
printed  pages,  with   236  illustrations,  extra  cloth,  $7  00;    leather,    raised  bands,  $8  00 
It  will  flU  a  place  which  no  other  work  can  occupy  I  ed  in  the   hape  of  a  complete  treatiseon  materia  med- 
ia the  library  of  the  physician,  .itudeut,  and  apothe-  |  ica,  and  the  medical  student  has  a  text-book   which, 
cary. — Boston  Med.and  Surg.  Journal,^o\.?i,y&'o6.  I  for  practical  utility  and  intrinsic  worth,  stands  au- 
The  Ame  lean  physician  now  has  all  that  is  need"  1  paralleled.— iY.  Y.  md.  Record,  Nov.  15, 1866. 


HsNRY  C.  Lea's  Publications— ( Ifa;:.  31ed.  and  Therapeutics).       13 


QRIFFITH  [ROBERT  E.),  M.D. 

A  UNIYERSAL  FORMULARY,  Containing  the  Methods  of  Prepar- 
ing and  Administering  Officinal  and  other  Medicines.     The  whole  adapted  to  Physician,  ard 
Pharmaceutists.     Third  edition,  thoroughly  revised,  with  numerous  additions,  b-  John  M 
Maisch,  Professor  of  Materia  Mediea  in  the  Philadelphia  College  of  Pharmacy.'  Inonelaro-e 
andhandsomeoctavovolumeofabout800pages:cloth,$4  50;  leather,  $5  50.   (Just  Ready  ) 
This  work  has  long  been  known  for  the  vast  amount  of  information  which  it  presents  in  a  con 
densed  form,  arranged  for  easy  reference.     The  new  edition  has  received  the  most  careful  revi- 
sion at  the  competent  hands  of  Professor  Maisch,  who  hns  brought  the  whole  up  to  the  standard  of 
the  most  recent  authorities.     More  than  eighty  new  headings  of  remedies  have  been  introduced 
the  entire  work  has  been  thoroughly  remodelled,  and  whatever  has  seemed  to  be  obsolete  has  been 
omitted.     As  a  comparative  view  of  the  United  States,  the  British,  the  German,  and  the  French 
Pharmacopoeias,  together  with  nn  immense  amount  of  unofficinal  formulas,  it  affords  to  the  prac- 
titioner and  pharmaceutist  an  aid  in  their  daily  avocations  not  to  be  found  elsewhere,  while  three 
indexes,  one  of  "Diseases  and  their  Remedies,"  one  of  Pharmaceutical  Names,  and  a  General 
Index,  afford  an  easy  key  to  the  alphabetical  arrangement  adopted  in  the  text. 


The  young  practitioner  will  find  the  work  invalu- 
able in  suggesting  eligible  modes  of  administering 
many  remedies. — Am.  Journ.  of  Pharm.,  Feb.  1874. 

Oar  copy  of  Griffith's  Formulary,  after  long  use, 
first  in  the  dispensing  shop,  and  afterwards  in  our 
medical  practice,  had  gradually  fallen  behind  in  the 
onward  march  of  materia  mediea,  pharmacy,  and 
therapeutics,  until  we  had  ceased  to  consult  it  a.s  a 
daily  book  of  reference.  So  completely  has  Prof. 
iNfiiisch  reformed,  remodelled,  and  rejuvenated  it  in 
the  new  edition,  we  shall  gladly  welcome  it  back  to 
our  table  again  beside  Dunglison,  Webster,  and  Wood 
&  Bache,  The  publisher  could  not  have  been  more 
tbrtunate  in  the  selection  of  an  editor.  Prof.  Maisch 
is  eminently  the  man  for  the  work,  and  he  has  done 
it  thoroughly  and  ably.  To  enumerate  the  altera- 
tions, amendments,  and  additions  would  be  an  end- 
less task;  everywhere  we  are  greeted  with  the  evi- 
dences of  his  labor.  Following  the  Formulary,  is  an 
addendum  of  useful  Recipes,  Dietetic  Preparations, 
I/ist  of  Incompatibles,  Posological  table,  table  of 
Pharmaceutical  Names,  Officinal  Prepai'ations   and 


Directions,  Poisons.  Aulidotes,  and  Treatment,  and 
copious  indices,  which  afford  ready  access  to  all  parts 
of  the  work.  We  unhesitatingly  commend  the  book 
as  being  the  best  of  its  kind,  within  our  knowledge. 
—Afla7ita  Med.  and  Surg.  Jnurn.,  Feb.  1874. 

To  the  druggist  a  good  formulary  is  simply  indis- 
pensable, and  perhaps  no  formulary  has  been  more 
extensively  used  than  the  well-known  work  before 
us.  Many  physicians  have  to  officiate,  also,  as  drue;- 
gists.  This  is  true  especially  of  the  country  physi- 
cian, and  a  work  which  shall  teach  him  the  means 
by  which  to  administer  or  combine  his  remedies  in 
the  most  efficacious  and  pleasant  manner,  will  al- 
ways hold  its  place  upon  his  shelf.  A  formulary  of 
this  kind  is  of  benefit  also  to  the  city  physician  in 
largest  practice.— CmcMmoii  CTinic.'Feb.  21,  1874. 

The  Formulary  has  already  proved  Itself  accepta- 
ble to  the  medical  profession,  and  we  do  not  hesitate 
to  say  that  the  third  edition  is  much  improved,  and 
of  greater  practical  value,  in  consequence  of  the  cai-e- 
ful  revision  of  Prof  Maisch.— C/tica^fo  Med.  Exam- 
iner, March  15,  1S7-1. 


j^LLIS  {BENJAMIN),  M.D. 

THE  MEDICAL  FORMULARY:  being  a  Collection  of  Prescriptions 

derived  from  the  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America 
and  Europe.    Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.    The 
whole  accompanied  with  a  few  brief  Pharmaceutic  and  Medical  Observations.    Twelfth  edi- 
tion, carefully  revised  and  much  improved  by  Albert  H.  Smith,  M.  D.    In  one  volume  8v®. 
of  376  pages,  extra  cloth,  $3  00.      {Lately  Puhlished.) 
This  work  has  remained  for  some  time  out  of  print,  owing  to  the  anxious  care  with  which  the 
Editor  has  sought  to  render  the  present  edition  worthy  a  continuance  of  the  very  remarkable 
favor  which  has  carried  the  volume  to  the  unusual  honor  of  a  Twelfth  Edition.     He  has  sedu- 
lously endeavored  to  introduce  in  it  all  new  preparations  and  combinations  deserving  of  confidence, 
besides  adding  two  new  classes,  Antemetics  and  Disinfectants,  with  brief  references  to  the  inhalation 
of  atomized  fluids,  the  nasal  douche  of  Thudichum,  suggestions  upon  the  method  of  hypodermic 
injection,  the  administration  of  anaesthetics,  &c.  ka.     To  accommodate  these  numerous  additions, 
he  has  omitted  much  which  the  advance  of  science  has  rendered  obsolete  or  of  minor  importance, 
notwithstanding  which  the  volume  has  been  increased  by  more  than  thirty  pages.     A  new  feature 
will  be  found  in  a  copious  Index  of  Diseases  and  their  remedies,  which  cnnnotbut  increase  the 
value  of  the  work  as  a  suggestive  book  of  reference  for  the  working  practitioner.    Every  precaution 
has  been  taken  to  secure  the  typographical  accuracy  so  necessary  in  a  work  of  this  nature,  and  it 
is  hoped  that  the  new  edition  will  fully  maintain  the  position  which  "  Ellis'  Formulary'"  hza 
long  occupied. 

pARSON  [JOSEPH),  M.D., 

V/  Professor  of  Materia.  Mediea  and  Pharmacy  in  the  University  of  Pennsylvania,  &c. 

SY^^OPSIS  OF  THE   COURSE   OF   LECTURES   ON  MATERIA 

MEDICA  AND  PHARMACY,  delivered  in  the  University  of  Pennsylvania.     "With  three 
Lectures  on  the  Modus  Operandi  of  Medicines.    Fourth  an  d  revised  edition,  extra  cloth  $3 


DUNGLISON'S  NEW  REMEDIES,  WITH  FORMULA 
FOR  THEIR  PREPARATION  AND  ADMINISTRA- 
TION". Seventh  edition,  with  extensive  additions. 
One  vol.  Svo.,  pp.  770 ;  extra  cloth.    $t  00. 

EOTLE'S  MATERIA  MEDICA  AND  THERAPEU- 
TICS. Edited  by  Joseph  Carson,  M.  D.  With 
ninety-eight  illustrations.  1  vol.  8vo.,  pp.  700,  ex- 
tra cloth.     $3  00. 

OHEISTISON'S  DISPENSATORY.  With  copious  ad- 
ditioas,  and  213  large  wood-eugravings.     By  R. 


Eglesfeld  Griffith,  M.  D.    One  vol.  Svo.,  pp.  1000 ; 
extra  cloth.    $4  00. 

CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  OF 
Alcoholic  Liquors  in  Health  and  Disease.  New 
edition,  with  a  Preface  by  D.  F.  Condie,  M.D.,  and 
explanationsof  scientific  words.  In  one  neat  ]2mo. 
volume,  pp.  178,  extra  cloth.     60  cents. 

De  JONGH  on  THE  THREE  KINDS  OF  COD-LIVEE 
Oil,  with  their  Chemical  and  Therapeutic  Pro- 
perties     1  vol.  12mo.,  cloth.     75  cents. 


14 


Henry  C.  Lea's  Publications — {Pathology^  &c.). 


TfENWICK  [SAMUEL),  M.D., 

Assistrint  Vhyaicion  to  ih^  London  Hn.tpifnl. 

THE  STUDENT'S  GUIDE  TO  MEDICAL  DIAGNOSIS.     From  the 

Third  Kevised  and  Enlarged  English  Edition  With  eighty-four  illustrations  on  wood. 
In  one  very  handsome  volume,  royal  12mo.,  cloth,  $2  25.  {Now  Ready.) 
The  very  great  success  which  this  work  has  obtained  in  England,  shows  that  it  has  supplied  an 
admitted  want  among  elementary  books  for  the  guidance  of  students  and  junior  practitioners. 
Taking  up  in  order  each  portion  of  the  body  or  class  of  dii^ease.  the  author  has  endeavored  to 
present  in  simple  language  the  value  of  symptoms,  so  as  to  lead  the  student  to  a  correct  appreci- 
ation of  the  pathological  changes  indicated  by  them.  The  latest  investigations  have  been  care- 
fully introduced  into  the  present  edition,  so  that  it  may  fairly  be  considered  as  on  a  level  with 
the  most  advanced  condition  of  medical  science.    The  arrangement  adopted  may  be  seen  from  the 

subjoined 

COJSriDEKrSElD     SXTlVrivI.A.E,"'?^'    OF    CODSTTEJISTTS. 

Chapter  I.  Introductory.  II.  Diseases  of  the  Heart  and  Pericnrdinm.  III.  Diseases  of  the 
Lungs.  IV.  Diseases  of  the  Throat  and  Larynx.  V.  Diseases  of  the  Kidneys.  VI.  Diseases  of 
the  Liver.  VII.  Diseases  of  the  Stomach.  VIII.  Diseases  of  the  Peritoneum  and  Intestines. 
IX.  Abdominal  Tumors.  X.  Diseases  of  the  Brain.  XI.  Fevers.  XII.  Rheumatism  and  Gout. 
XIII.  Diseases  of  the  Skin. 


G 


BEEN  [T.  HENRY),  M.D., 

Lecturer  on  Pathology  and  Morbid.  Anatomy  at  Charing -C1ro.^s  Bonpital  Medical  School. 

PATHOLOGY  AND  MORBID  ANATOMY.     With  numerous  Illus- 
trations on  Wood.     In  one  very  handsome  octavo  volume  of  over  250  pages,  extra  cloth, 
$2  50.      (Lately  Published.) 
We  have  been  very  much  pleased  by  our  perusal  of  |  thology  and  moibid  anatomy.  The  author  shows  that 


this  little  volume.  It  i.s  the  only  one  of  the  kind  with 
which  we  are  acquainted,  and  practitioners  as  well 
as  .students  will  find  it  a  very  useful  guide;  for  the 
information  is  up  to  the  day,  well  and  compactly  ar- 
ranged, without  being  at  all  ac'i.'aiy.— London  Lan- 
cet, Oct.  7,  1871. 

It  embodies  in  a  comparatively  small  space  a  clear 
statement  of  the  present  state  of  our  knowledge  of  pa- 

GLUGE'S  ATLAS  OF  PATHOLOGICAL  HISTOLOGY 
Translated,  with  Notes  and  Additions,  by  Joseph 
Lbidy,  M.  D.  In  one  volume,  very  large  imperial 
quarto,  with  320  copper-plate  figur'es,  plain  and 
colored,  extra  cloth.     $4  00. 

LA  EOCHE  ON  YELLOW  FEVER,  considered  in  its 
Historical,  Pathological,  Etiological,  and  Therapeu- 
tical Relations.  In  two  large  and  handsome  octavi 
volumes  of  nearly  L500  pages,  extra  cloth.     $7  00 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS.    1  vol   8vo.,  pp.  son,  extra  cloth.     %?•  .')0 

WHATTOOBSERVEATTHEBEDSIDEAND  AFTEi 
Death  in  Medical  Cases.  Published  under  thi 
Muthovity  of  the  London  Society  for  Medical  Obser 


he  has  been  not  only  a  student  of  the  teachings  of  his 
cnnfrkrex  in  this  branch  of  science,  but  a  practical 
and  conscientious  laborer  in  the  post-mortem  cliam- 
ber.  The  work  will  prove  a  useful  one  to  the  great 
mass  of  students  and  practitioners  whose  time  for  de- 
votion to  this  class  ofstudies is  limited.  — .4m  Journ. 
of  Syphilography,  April,  1872. 


vation.     From  the   second  London  edition.     1  vo 
royal  12mo.,  extra  cloth.     $1  00. 

LAYCOCK'S  LECTURES  ON  THE  PRINCIPLES 
AND  Methods  of  Medical  Observation  and  Re- 
search. For  the  use  of  advanced  students  and 
junior  practitioners.  In  one  very  neat  royal  12tii'* 
volume,  extra  cloth.    Sll  00. 

SARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  Additions  by  D.  F.  Condie, 
«    n       1  vol    Sto.,  pp    000.  cloth       t?  ."SO 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN  ACUTE 
Diseases.  In  one  neat  octavo  volume,  of  320  pages, 
extra  cloth.    *2  50. 


flROSS  [SAMUEL  D.),  M.  D., 

^J~  ProfesaoT  of  Surgery  in  the  Jefferson  Medical  College  of  Philad.elphia. 

ELEMENTS    OF    PATHOLOGICAL   ANATOMY.     Third    edition, 

thoroughly  revised  and  greatly  improved.  In  one  large  and  very  handsome  octavo  volume 
of  nearly  800  pages,  with  about  three  hundred  and  fifty  beautiful  illustrations,  of  which  a 
large  number  are  from  original  drawings  ;   extra  cloth.     $4  00. 

TONES  [G.  RANDEIELD),  F.R.S.,  and  SIEVEKING  [ED.  K),  M.D., 

^  Assiidant  Physicians  and  Lecturers  in  St.  Mary's  Hospiinl 

A  MANUAL  OF   PATHOLOGICAL  ANATOMY.     First  American 

edition,  revised.  With  three  hundred  and  ninety-seven  handsome  wood  engravings.  In 
one  large  and  beautifully  printed  octavo  volume  of  nearly  750  pages,  extra  cloth,  $3  60. 

or  URGES  [OCTA  VIUS),  M.D.  Cantab. 

^  Fellow  oft^e  Royal  (lolleoe  of  Phy.'^icians.  &o.  d-c. 

AN   INTPvODUCTION    TO    THE    STUDY   OF    CLINICAL   MED- 

ICINB.     Being  a  Guide  to  the  Investigation  of  Di.sease,  for  the  Use  of  Students.     In  one 

handsome  12mo.  volume,  extra  cloth,  *1  25.  {Now  Ready.) 
Table  or  Contents.  I.  The  Sort  of  Help  needed  by  the  Student  at  the  Bedside.  II.  Some 
General  Rules  with  Reference  to  the  Examination  of  Patients  III.  The  Family  and  Personal 
History  of  the  Patient.  IV.  Examination  of  the  Functions.  V.  Examin;ition  of  the  Phenomena 
connected  with  the  Brain  and  Cord  VI.  The  Physical  Examination  of  the  Che.st,  its  Inspection 
and  P;ilp;ition.  VII.  Percussion  Applied  to  the  Heart  and  Lungs.  VIIl".  Auscultation  of  the 
Chest.  IX.  Examination  of  the  Abdomen  and  of  the  Secretions.  X.  The  Diagnosis.  XI.  The 
Treatment. 


Henry  C  Lea's  Publications — {Practice  of  Medicine). 


I  ft 


J^LINT  {AUSTIN),  M.D., 

-*•  Professor  of  the  Principles  and  Practice  of  Medicine  in  Belleviie  Med.  College,  K.  Y. 

A   TREATISE    ON    THE    PRINCIPLES    AND    PRACTICE    OF 

MEDICINE;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Fourth 
edition,  revised  and  enlarged.  In  one  large  and  closely  printed  octavo  volume  of  about  1 1 00 
pages ;  handsome  extra  cloth,  $6  00  ;  or  strongly  bound  in  leather,  with  raised  bands,  $7  00. 
{.Just.  Issued.) 

By  common  consent  of  the  English  and  American  medical  press,  this  work  has  been  assigned 
to  the  highest  position  as  a  complete  and  compendinus  text-book  on  the  most  advanced  condition 
of  medical  science.  At  the  very  moderate  price  at  which  it  is  offered  it  will  be  found  one  of  the 
cheapest  volumes  now  before  the  profession. 


Admirable  and  uaequalled.  —  Western  Journal  of 
Medicine,  Nov.  1S69. 

Dr.  Fliut's  work,  though  claiming  no  higher  title 
than  that  of  a  tpxt-book,  is  really  more.  He  is  a  man 
of  large  clinical  experience,  and  his  book  is  full  of 
guch  masterly  descriptions  of  disease  as  can  only  be 
drawn  by  a  man  intimately  acquainted  with  their 
various  forms.  It  is  not  so  long  since  we  had  the 
pleasure  of  reviewing  his  first  edition,  and  we  recog- 
nize a  great  improvement,  especially  in  the  general 
partof  the  work.  It  is  a  work  which  we  can  cordially 
recommend  to  our  readers  as  fully  abreast  of  the  sci- 
ence of  the  day. — Edinburgh  Med.  Journal,  Oct.  '69. 

One  of  the  best  works  of  the  kind  for  the  practi- 
tioner, and  the  most  convenient  of  all  for  the  student. 
— Am.  Journ.  Med  Sciences,  Jan.  1S69. 

This  work,  which  stands  pre-eminently  as  the  ad- 
vance standard  of  medical  science  up  to  the  present 
time  in  the  practice  of  medicine,  has  for  its  author 
one  who  is  well  and  widely  known  as  one  of  the 
leading  practitioners  of  this  continent.  In  fact,  it  is 
seldom  that  any  work  is  ever  issued  from  the  press 
more  deserving  of  universal  recommendation. — Do- 
minion Med  Journal,  May,  1869. 

The  third  edition  of  this  most  excellent  book  scarce- 
ly needs  any  commendation  from  us  The  volume, 
as  it  stands  now,  is  really  a  marvel :  first  of  all,  it  is 


sxcellently  printed  and  bound — and  we  encounter 
that  luxury  of  America,  the  ready-cut  pages,  which 
the  Yankees  are  'cute  enough  to  insist  upon — nor  are 
these  by  any  means  trifles  ;  but  the  contents  of  the 
book  are  astonishing.  Not  only  is  it  wonderful  that 
iny  one  man  can  hAve  grasped  in  his  mind  the  whole 
icope  of  medicine  with  that  vigor  which  Dr.  Flint 
ihows,  but  the  condensed  yet  clear  way  in  which 
this  is  done  is  a  perfect  literary  triumph.  Dr.  Flint 
IS  pre-eminently  one  of  the  strong  men,  whose  right 
■,o  do  this  kind  of  thing  is  well  admitted  ;  and  we  say 
10  more  than  the  truth  when  we  affirm  that  he  is 
7ery  nearly  the  only  living  man  that  could  do  it  with 
iuch  results  as  the  volume  before  ua. —  The  London 
Practitioner,  March,  1S69. 

This  is  in  some  respects  the  best  text-book  of  medi- 
jine  in  oar  language,  and  it  is  highly  appreciated  on 
:he  other  side  of  the  Atlantic,  inasmuch  as  the  first 
jdition  was  exhausted  in  a  few  months.  The  second 
jdition  was  little  more  than  a  reprint,  but  the  present 
ias,  as  the  author  says,  been  thoroughly  revised. 
Much  valuable  matter  has  been  added,  and  by  mak- 
ing the  type  smaller,  the  bulk  of  the  volume  is  not 
much  increased.  The  weak  point  in  many  American 
Works  is  pathology,  but  Dr.  Flint  has  taken  peculiar 
pains  on  this  point,  greatly  to  the  value  of  the  book. 
— London  Med.  Times  and  Gazette,  Feb.  6,  1S69. 


F 


A  VF  (F.  W.),  M.  D.,  F.  R.  S., 

Senior  Asst.  Physician  to  and  Lecturer  on  Physiology,  at  Gruy's  Hospital,  &c. 

A  TREATISE  ON  THE    FUNCTION  OF  DIGESTION;  its  Disor- 

ders  and  their  Treatment.     From  the  second  London  edition.     In  one  handsome  volume, 
small  octavo,  extra  cloth,  $2  00.      {Lately  Publisked.) 
The  work  before  us  is  one  which  deserves  a  wide     treatise,  and  sufficiently  exhaustive  for  all  practical 
airculation.     We  know  of  no  better  guide  to  the  study     puiposes. — Leavenworth  Med.  Herald,  July,  1S69. 
of  digestion  and  its  disorders,— Si.  Louvi  Med.  and        ^  ^^ry  valuable  work  on  the  subject  of  which  It 
Surg.  Journal,  July  10,  1669.  treats.     Small,  yet  it  is  full  of  valuable  information. 

A  thoroughly  good  book,  being  a  careful  systematic     — Cincinnati  Med.  Repertory,  June,  1869. 


JD  Y  THE  SA  ME  A  UTHOR,     {N'-arly  Ready. ) 

A  TREATISE  ON  FOOD  AND  DIETETICS,  PHYSIOLOGI- 
CALLY AND  THERAPEUTIC  ALLY  CONSIDERED.  In  one  handsome  octavo  volume 
of  nearly  600  pages. 

SUMMARY  OF  CONTENTS. 

Introductory  Remarks  on  the  Dynamic  Relations  of  Food — On  the  Origination  of  Food — The 
Constituent  Relations  of  Food — Alimentary  Principles,  their  Classiftcation,  Chemical  Relations, 
Digestion,  Assimilation,  and  PhysioIogiL^al  Uses — Nitrogenous  Alimentary  Principles — Non-Ni- 
trogenous Alimentary  Principles — The  Carbo-Hydrates — The  Inorganic  Alimentary  Principles — 
Alimentary  Substances — Animal  Alimentary  Substances — Vegetable  Alimentary  Substances — 
Beverages — Condiments — The  Preservation  of  Food — Principles  of  Dietetics — Practical  Dietetics 
— Diet  of  Infants — Diet  for  Training — Therapeutic  Dietetics — Dietetic  Preparations  for  the  Inva- 
lid— Hospital  Dietaries. 

pHAMBERS  [T.  K.),  M.D., 

^  Consulting  Physician  to  St.  Mary's  Hospital,  London,  &e. 

THE  INDIGESTIONS;  or.  Diseases  of  the  Dig:estive  Organs  Functionally 

Treated.    Third  and  revised  Edition.    In  one  handsome  octavo  volume  of  383  pages,  extra 

cloth.     $3  00.      {Lately  Published.) 
From  this  purely  mate-  rial  point  of  view,  setting  I  tents  to  his  memory  would  find  its  price  an  invest- 
aside  its  higher  claims  to  merit,  we  know  of  no  more  |  meat  of  capital  that  returned  him  a  most  usurious 
desirable  acquisition  to  a  physician's  library  than  I  rate   of  interest.— A^.    Y.  Medical  Gazette,  Jan,  28, 
the  book  before  us.     He  who  should  commit  its  con-     1871 


^F  THE  SAME  AUTHOR.     {Lately  Published.) 

RESTORATIVE  MEDICINE.  An  Harveian  Annual  Oration,  deliv- 
ered at  the  Royal  College  of  Physicians,  London,  on  June  24,  1871.  With  Two  Sequels. 
In  one  very  handsome  volume,  small  12mo.,  extra  cloth,  $1  00. 


16 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


LTARTSHORNE  [HENRY),  M.D., 

XJL  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEDI- 
CINE. A  handy-book  for  Students  and  Practitioners.  Fourth  edition,  revised  and  im- 
proved.    In  one  hand&ome  royal  J2mo.  volume.      {Preparing.) 

This  little  epitome  of  medical  knowledge  has  al- 1  mulas  are  appended,  intended  as  examples  merely, 
ready  heen  noticed  by  us.  It  is  a  vade  mecum  of  nut  as  guides  for  unthinking  practitioners.  A  corn- 
value,  including  in  a  short  space  mosr  of  what  is  es-  plete  index  facilitates  the  use  of  this  little  volume,  in 
sential  in  the  science  and  practice  of  medicine.  The  '  which  all  important  remedies  lately  introduced,  such 
third  edition  is  well  up  to  the  present  day  in  the  as  chloral  hydrate  and  carbolic  acid,  have  received 
modern  methods  of  treatment,  and  iu  the  use  of  newly  ,  their  full  share  of  attention. —^m.  Journ.  of  Pharm., 

'      Nov.  1871. 


discovered  drugs. — Boston  Med.  and  Surg.  Journal, 
Oct.  19,  1S71. 

Certainly  very  few  volumes  contain  so  much  pre- 
cise information  within  so  small  a  compass. — N.  Y. 
Med.  Journal,  Nov.  1871. 

The  diseases  are  conveniently  classified;  symptoms, 
causation,  diagnosis,  proguosis,  and   treatment  are 

carefully  considered,   the  whole   being  marked    by  ^  demand. — Gineinnati  Med.  Bepertory,  2iov.  1S71 
briefness,  but  clearness  of  expression.     Over  2.J0  for- 


It  is  an  epitome  of  the  whole  science  and  practice 
of  medicine,  and  will  be  found  most  valuable  to  the 
practitioner  for  easy  reference,  and  especially  to  the 
student  in  attendance  upon  lectures,  whose  time  is 
too  much  occupied  with  many  studies,  to  consult  the 
larger  works.     Such  a  work  must  always  be  in  great 


TU:ATS0N  [THOMAS],  M.  D.,  §-c. 

LECTURES     ON     THE     PRINCIPLES    AND    PRACTICE    OF 

PHYSIC.  Delivered  at  King's  College,  London.  A  new  American,  from  the  Fifth  re- 
vised and  enlarged  English  edition.  Edited,  with  additions,  and  several  hundred  illus- 
trations, by  Henry  Haetshoeke,  M.D.,  Professor  of  Hygiene  in  the  Univer.sity  of  Penn- 
sylvania. In  two  large  and  handsome  8vo.  vols.  Cloth,  $9  00  ;  leather,  $11  00.  {Just  Issued.) 
At  length,  after  many  months  of  expectation,  we 
have  the  satisfaction  of  finding  ourselves  this  week  in 
possession  of  a  revised  and  enlarged  edition  of  Sir 
Thomas  Watson's  celebrated  Lectures  It  is  a  sub- 
ject for  congratulation  and  for  thankfulness  that  Sir 
Thomas  Watson,  during  a  period  of  comparative  lei- 
sure, after  a  long,  laborious,  and  most  honorable  pro- 
fessional career,  while  retaining  full  possession  of  his 
high  mental  faculties,  should  have  employed  the  op- 
portunity to  submit  his  Lectures  to  a  more  thorough 
revision  than  was  pcjssible  during  the  earlier  and 
busier  period  of  his  life.  Carefully  passingin  review 
some  of  the  most  intricate  and  important  pathological 
and  practical  questions,  the  results  of  his  clear  insight 
and  his  calm  judgment  are  now  recordedfor  the  bene- 
fit of  mankind,  in  language  which,  lor  precision,  vigor, 
and  classical  elegance,  has  rarely  been  equalled,  and 
never  surpassed  The  revision  has  evidently  been 
most  carefully  done,  and  the  results  appear  in  almost 
every  page. — Brit.  Med.  Journ.,  Oct.  1-1,  1871. 

The  lectures  are  so  well  known  and  so  justly 
appreciated,  that  it  is  scarcely  necessary  to  do 
more  than  call  attention  to  the  special  advantages 
of  the  last  over  previous  editions.  In  the  revi- 
sion, the  author  has  displayed  all  the  charms  and 


advantages  of  great  culture  and  a  ripe  experience 
combined  with  the  soundest  judgment  and  sin- 
cerity of  purpose.  The  author's  rare  combination 
of  great  scientific  attainments  combined  with  won- 
derful forensic  eloquence  has  exerted  extraordinary 
influeuce  over  the  last  two  generations  of  physicians. 
His  clinical  descriptions  of  most  diseases  have  never 
been  equalled  ;  and  on  this  score  at  least  his  work 
will  live  long  in  the  future.  The  work  will  be 
sought  by  all  who  appi'eciate  a  great  book. — Ariier. 
Journal  of  Syphilography,  July,  1S72. 

We  are  exceedingly  gratified  at  the  reception  of 
this  new  edition  of  Watson,  pre-eminently  the  priuce 
of  English  authors,  on  "Practice."  We,  who  read 
the  fir.^t  edition  as  it  came  to  us  tardily  and  in  frag- 
ments through  the  "Medical  Kews  and  Librar;. ,  ' 
shall  never  foiget  the  great  pleasure  and  profit  we 
derived  from  its  graphic  delineations  of  disease,  its 
vigorous  style  aud  splendid  Euglish.  Maturity  of 
years,  extensive  observation,  profound  research, 
and  yet  continuous  enthusiasm,  have  combined  to 
give  us  in  this  latest  edition  a  model  of  professional 
excellence  in  teaching  with  rare  beauty  iu  the  mode 
of  communication.  But  this  classic  needs  no  eulo- 
gium  of  ours. — Chicago  Med.  Journ.,  July,  1872. 


ryUNGLISON,  FORBES,  TWEEDIE,  AND  CONOLLY. 

THE  CYCLOPiEDIA  OF   PRACTICAL  MEDICINE:   comprising 

Treatises  on  the  Nature  and  Treatment  of  Diseases,  Materia  Medica  and  Therapeutics, 
Diseases  of  Women  and  Children,  Medical  Jurisprudence,  &c.  &c.  In  four  large  super-royal 
octavo  volumes,  of  3254  double-columned  pages,  strongly  and  handsomely  bound  in  leather, 
$15  ;  extra  cloth.     $11. 

*^*  This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed 

sixty-eight  distinguished  physicians. 


pox  [  WILSON),  M.D., 

-L  Holme  Prof,  of  Clinical  Med.,  University  Coll.,  London. 

THE  DISEASES  OF  THE  STOMACH:  Being  the  Third  Edition  of 

the  "Diagnosis  and  Treatment  of  the  Varieties  of  Dyspepsia."     Revised  and  Enlarged. 
With  illustrations.     In  one  handsome  octavo  volume. 
*~*  Publishing  in  the  "  Medical  News  and  Library"  for  1873  and  1874. 
The  present  edition  of  Dr.  Wilson  Fox's  very  admi-  j      Dr.  Fox  has  put  forth  a  volume  of  uncommon  ex- 
rable  work  differs  from  the  preceding  in  that  it  deals  I  cellence,  which  we  feel  very  sure  will  take  a  high 
with  other  maladies  thau  dyspepsia  only. — London  |  rank  among  works  that  treat  of  the  stomach.  — .4wi. 
Med.  Times,  Feb.  8,  1873.  |  Practitioner,  March,  1S73. 


JDRINTON  [WILLIAM),  M.D.,  F.R.S. 

LECTURES  ON  THE  DISEASES  OF  THE   STOMACH;   with  an 

Introduction  on  its  Anatomy  and  Physiology.  From  the  second  and  enlarged  London  edi- 
tion. With  illustrations  on  wood  In  one  handsome  octavo  volume  of  about  300  pages, 
extra  cloth.     $3  25. 


Henry  C.  Lea's  Publications — (Diseases  of  Lungs  and  Heart).     17 


WLINT  {A  USTIN) ,  M.D., 

J.  Professor  of  the  Princi'ples  and  Practice  of  Medicine  in  Bellevue  Hospital  Med.  College,  N.  T. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF   THE  HEART.     Second  revised  and  enlarged 

edition.     In  one  octavo  volume  of  550  pages,  with  a  plate,  extra  cloth,  §4. 

The  author  has  sedulously  improved  the  opportunity  afforded  him  of  revising  this  work.   Portions 

of  it  have  been  rewritten,  and  the  whole  brought  up  to  a  level  with  the  most  advanced  condition  of 

science.  It  must  therefore  continue  to  maintain  its  position  as  the  standard  treatise  on  the  subject. 

Dr.  Flint  chose  a  difficult  subject  for  his  researches,  '  able  for  purposes  of  illustration,  in  connection  with 
and  has  shown  remarkable  powers  of  observation,  i  cases  which  have  been  reported  by  other  trustworthy 
and  reflection^  as  well  as  great  industry,  in  his  treat-    observers. — Brit,  and  For.  Med.-Chirurg.  Review. 


ment  of  it.  His  book  must  be  considered  the  fullest 
and  clearest  practical  treatise  on  those  subjects,  and 
should  be  in  the  hands  of  all  practitioners  and  stu- 
dents. It  is  a  credit  to  American  medical  literature. 
— Amer.  Journ.  of  the  Med.  Sciences,  July,  1S60. 

We  question  the  fact  of  any  recent  American  author 
in  our  profession  being  more  extensively  known,  or 
more  deservedly  esteemed  in  this  country  than  Dr. 
Flint.  We  willingly  acknowledge  his  success,  more 
particularly  in  the  volume  on  diseases  of  the  heart, 


In  maliing  an  extended  personal  clinical  study  avail-  i  News. 


I      In  regard  to  the  merits  of  the  work,  we  have  do 
'  hesitation  in  pronouncing  it  full,  accurate,  and  judi- 
cious.    Considering  the  present  state  of  science,  such 
a  work  was  much  needed.   It  should  be  in  the  hands 
of  every  practitioner. — Chicago  Med.  Journ. 

With  more  than  pleasure  do  we  hail  the  advent  of 
this  work,  for  it  fills  a  wide  gap  on  the  list  of  text- 
books for  our  schools,  and  is,  for  the  practitioner,  the 
most  valuable  practical  work  of  its  kind. — N.  0.  Med. 


B 


Y  THE  SAME  AUTHOR. 

PRACTICAL  TREATISE  0\  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  extra  cloth,  $4  50. 

which  pervades  his  whole  work  lend  an  additional 
force  to  its  thoroughly  practical  character,  which 
cannot  fail  to  obtain  for  it  a  place  as  a  standard  work 
on  diseases  of  the  respiratory  system. — London 
Lancet,  Jan.  1?,  1S67. 

This  is  an  admirable  book.  Excellent  in  detail  and 
execution,  nothing  better  could  be  desired  by  the 
practitioner.  Dr.  Flint  enriches  his  subject  with 
much  solid  and  not  a  little  original  observation. — 
Ranking's  Abstract,  Jan.  1867. 


Dr.  Flint's  treatise  is  one  of  the  most  trustworthy 
guides  which  he  can  consult.  The  style  is  clear  and 
distinct,  and  is  also  concise,  being  free  from  that  tend- 
ency to  over-refinement  and  unnecessary  minuteness 
which  characterizes  many  works  on  the  same  sub- 
ject.—i)«6Zm  Medical  Press,  Feb.  6,  1867. 

The  chapter  on  Phthisis  is  replete  with  interest ; 
and  his  remarks  on  the  diagnosis,  especially  in  the 
early  stages,  are  remarkable  for  their  acumen  and 
great  practical  value.  Dr.  Flint's  style  is  ciear  and 
elegant,  and  the  tone  of  freshness  and  originality 


pOLLER  {HENRY  WILLIAM),  M.  D., 

-*■  Physician  to  St   George's  Hospital,  London. 

ON  DISEASES  OF  THE   LUNGS   AND   AIR-PASSAGES.     Their 

Pathology,  Physical  Diagnosis,  Symptoms,  and  Treatment.  Prom  the  second  and  revised 
English  edition.  In  one  handsome  octavo  volume  of  about  500  pages,  extra  cloth,  $3  50. 
Dr.  Fuller's  work  on  diseases  of  the  chest  was  so  accordingly  we  have  what  might  be  with  perfect  j  us- 
favorably  received,  that  to  many  who  did  not  know  tice  styled  an  entirely  new  work  from  his  pen,  the 
the  extent  of  his  engagements,  it  was  a  matter  of  won-  portion  of  the  work  treating  of  the  heart  and  great 
der  that  it  should  be  allowed  to  remain  three  years  vessels  being  excluded.  Nevertheless,  this  volume  is 
out  of  print.  Determined,  however,  to  improve  it,  '  of  almost  equal  size  with  the  first. — London  Medical 
Dr.  Fuller  would  not  consent  to  a  mere  reprint,  and  ;  Times  and  Gazette,  July  2C,  1867. 


yf/'ILLIAMS  (C.  J.  B.),  M.D., 

Senior  Consulting  Physician  to  the  Hospital  for  Oonsicmption,  Brompton,  and 

1J/7LLIAMS  {CHARLES  T.),  M.D., 

Physician  to  the  Hospital  for  Consumption. 

PULMONARY  CONSUMPTION;  Its  Nature,  Varieties,  and  Treat- 

ment.     With  an  Analysis  of  One  Thousand  eases  to  exemplify  its  duration.     In  one  neat 
octavo  volume  of  about  350  pages,  extra  cloth.      (Just  Issued.)      $2  50. 


He  can  still  speak  from  a  more  enormous  experi- 
ence, and  a  closer  study  of  the  morbid  proces.ses  in- 
volved in  tuberculosis,  than  most  living  men.  He 
owed  it  to  himself,  and  to  the  importance  of  the  sub- 
ject, to  embody  his  views  in  a  separate  work,  and 
we  are  glad  that  he  has  accomplished  this  duly. 
After  all,  the  grand  teaching  which  Dr  Williams  has 
for  the  profession  is  to  be  found  in  his  therapeutical 
chapters,  and  in  the  history  of  individual  cases  ex- 
tended, by  dint  of  care,  over  ten,  twenty,  thirty,  and 
even  forty  years. — London  Lancet,  Oct.  21,  187 1. 


His  results  are  more  favorable  than  those  of  any  |  -i?  ISJl 


previous  author;  but  probably  there  is  no  malady, 
the  treatment  of  which  has  been  so  much  impi-oved 
within  the  last  twenty  years  as  pulmonary  consump- 
tion. To  ourselves,  Ur.  Williams's  chapters  on  Treat- 
ment are  amongst  the  most  valuable  and  attractive  in 
the  book,  and  would  alone  render  it  a  standard  work 
of  reference.  In  conclusion,  we  would  record  our 
opinion  that  Dr.  Williams's  great  reputation  is  fully 
maintained  by  this  book.  It  is  undoubledly  one  of 
the  most  valuable  works  in  the  language  upon  any 
■pecial  disease.— io?id.  Med.  Times  and  Gaz.,  2^ov. 


LA   EOCHE   ON  PNEUMONIA.     1  vol.  8vo.,  extra  ,  SMITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE 


cloth,  of  .500  pages      Price  $.3  00 

BUCKLER  ON  FIBRO-BRONCHITIS  AND  RHEU- 
MATIC PNEUMONIA.     1  vol.  Svu.     $1  2.5. 

FISKE  FUND  PRIZE  ESSAYS  ON  CONSUMPTION. 
1  vol  8vo,,  extra  cloth.    $1  00. 


MEDIABLE  STAGES.     1  vol.  Svo.,  pp.  254.     $2  25. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART  AND 
GREAT  VESSELS.  Third  American  edition.  In 
1  vol.  Svo.,  420  pp.,  cloth.     $3  00. 


18  Hbnrt  C.  Lea's  Publications — {Practice  of  Medicine). 

f>OBERTS  (  WILLIAM),  M.  D.. 

•^^  Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine.  &c. 

A  PRACTICAL  TREATISE   OX  TJRIXARY  AND   REXAL   DIS- 

EASES,  including  Urinary  Deposits.  Illustrated  by  numerous  cases  and  engrayingrs.  Sec- 
ond American,  from  the  Second  Revised  and  Enlarged  London  Edition.  Tn  one  large 
and  handsome  octavo  volume  of  616  pages,  with  a  colored  pla.te  ;  extra  cloth,  $4  50.  {Just 
Issued.) 

The  author  has  subjected  this  work  to  a  very  thorough  revision,  and  has  sought  to  embody  in 
it  the  results  of  the  latest  experience  and  investigations.  Although  every  effort  has  been  made 
to  keep  it  within  the  limits  of  its  former  size,  it  has  been  enlarged  by  a  hundred  pages,  many 
new  wood-cuts  have  been  introduced,  and  also  a  colored  plate  representing  the  appearance  of  the 
different  varieties  of  urine,  while  the  price  has  been  retained  at  the  former  very  moderate  rate. 

diseases  we  have  examined     It  is  peculiarly  adapted 


The  plan,  it  will  thus  be  seen,  is  very  complete, 
ani  the  manner  in  which  it  has  been  carried  out  is 
in  the  highest  degree  satisfactory.  The  characters 
of  the  different  deposits  are  very  well  described,  and 


to  the  wants  of  the  majority  of  American  practition- 
ers from  its  clearness  and  simple  announcement  of  the 
facts  in  relation  to  diagnosis  and  treatment  of  urinary 


the  microscopic  appearances  they  present  are  illus-  j  disorders,  and  contains  in  condensed  form  the  investi- 
trated  by  numerous  well  executed  engravings  It  !  gations  of  Bence  .Jones,  Bird,  Beale,  Hassall.  Prout, 
only  remains  to  us  to  strongly  recommend  to  our  j  and  a  host  of  other  well-known  writers  upon  this  sub- 
readers  Dr.  Roberts's  work,  as  coniaining  an  admira-  |  ject.  The  characters  of  urine,  physiological  and  pa- 
ble  n'xume  of  the  present  state  of  knowledge  of  uri-  |  thological,  asindicated  to  the  naked  eye  as  well  as  by 
nary  diseases,  and  as  a  safe  and  reliable  guide  to  the  microscopical  and  chemical  inrestigations,  are  con- 
clinical  observer. — Edin.  Med.  Jnur.  cisely  represented  both  by  description  and  by  well 
The  most  complete  and  practical  treatise  upon  renal  I  executed  engravings.— Cincmnaii  Juur^i.  of  Med. 


DASH  AM  (W.E.),  M.D., 

-*-'  Senior  Physician  to  the  Westmin-iter  Hospital,  &c. 

RENAL  DISEASES:  a  Clinical  Guidetotheir  Diagnosis  and  Treatment. 

With  illustrations.     In  one  neat  royal  12mo.  volume  of  304  pages.    $2  00. 

The  chapters  on  diagnosis  and  treatment  are  very  [  details  of  larger  books  here  acquire  a  new  interest 
good,  and  the  student  and  young  practitioner  will  1  from  the  author's  arrangement.  This  part  of  the 
find  them  full  of  valuable  practical  bints.     The  third  I  book  is  full  of  good  work. — Brit,  and  For.  Medieo- 


part,  on  the  urine,  is  excellent,  and  we  cordially 
recommend  its  perusal.  The  author  has  arranged 
his  matter  in  a  somewhat  ncivel,  and,  we  think,  use- 
ful form.  Here  everything  can  be  easily  found,  and, 
what  is  more  important,  easily  read,  for  all  the  dry 


Ihirurgical  Bevieu),  July,  1870. 

The  easy  descriptions  and  compact  modes  of  state- 
ment render  the  book  pleasing  and  convenient. — Ani.. 
Journ.  Med.  Sciences,  July,  1870. 


J 


ONES  [G.  HANDFIELD),  M.  D., 

Physician  to  St.  Mary's  Uo.spital,  &c. 

CLINICAL    OBSERVATIONS    ON    FUNCTIONAL   NERVOUS 

DISORDERS.     Second  American  Edition.     In  one  handsome  octavo  volume  of  348  pages, 
extra  cloth,  $3  25. 

Taken  as  a  whole,  the  work  before  us  furnishes  a  I  titioner  will  derive  from  it  many  a  suggestive  hint  to 
short  but  reliable  account  of  the  pathology  and  treat-     lid  him  in  the  diagnosis  of  "nervous  cases,"  and  in 
ment  of  a  class  of  very  common  but  certainly  highly  I  ietermining  the  true  indications  for  their  ameliora- 
obscnre  disorders.    The  advanced  student  will  find  it  I  tion  or  cure. — Amer.  Journ.  Med.  Sci.,  Jan.  1867. 
a  rich  mine  of  valuable  facts,  while  the  medical  prac-  | 


T  INCOLN  [D.  F.).  M.D., 

-*-'  Ph'/.ncian  to  the  Department  of  Nervous  Diseases,  Boston  Dispensnry. 

ELECTRO  THERAPEUTICS  ;  4  Concise  Manual  of  Medical  Electri- 

city.     In  one  very  neat  royal  12mo.  volume,  with  Illustrations. 
The  chief  aim  cf  the  present  volume  has  been  the  analysis  of  the  principles  which   ought  to 
govern  our  use  of  Electricity.     The  portions  describing  the  practical  applications  which  have  been 
made  of  it  in  various  disorders,  may  be  found  incomplete,  but  it  is  hoped  that  enough  has  been 
said  to  satisfy  the  needs  of  the  general  practitioner. — Preface. 

STCrDVC3S/I.A.I?,-5^"    or'    OOXsTTBlSrTS. 
Chapter  I.    Physical  Laws — 11.    Modes  of  Generating  Electricity. — III.    Physiology  — TV. 
Ditignosis. — V.   Methods  of  Applying  Electricity. — VI.   Medical  and  Surgical  Practice. — VII. 
Cautions. — VIII.  Apparatus. 

^LADE  [D.  D.),  M.D. 

DIPHTHERIA;  its  Nature  and  Treatment,  with  an  account  of  the  His- 
tory of  its  Prevalence  in  various  Countries.  Second  and  revised  edition.  In  one  neat 
royal  12mo.  yolame,  extra  cloth.     $1  25. 

TTdDSON  {A.),  M.  D.,  M.  R.  L  A., 

■^-*-        Physician  to  the  Meath  Hospital. 

LECTURES  ON  THE   STUDY  OF  FEVER.     In  one  vol.  8vo.,  extra 

Cloth,  $2  50.  

r  TONS  {ROBERT  D.),  K.C.C. 
A  TREATISE  ON   FEVER.     In  one  octavo  volume  of  3G2  pages; 

cloth.     $2  25. 


Henry  C.  Lea's  Publications — (Venereal  Diseases,  etc.). 


19 


f>UMSTEAD  {FREEMAN  J.),  M.D., 

•'-^         Professor  of  Venereal  Diseases  at  the  Vol.  of  Phys  and  Sicrg.,  New  York,  &e. 

THE    PATHOLOGY   AND   TREATMENT   OF   VENEREAL  DIS- 
EASES.    Including  the  results  of  recent  investigations  upon  the  subject.     Third  edition, 
rev'ised  and  enlarged,  with  illustrations.     In  one  large  and  handsome  octavo  volume  of 
over  700  pages,  extra  cloth,  $5  00  ;  leather,  $6  00.      (Just  Issued.) 
In  preparing  this  standard  work  again  for  the  press,  the  author  has  subjected  it   to  a  very 
thorough  revision.    Many  portions  have  been  rewritten,  and  much  new  matter  added,  in  order  to 
bring  it  completely  on  a  level  with  the  most  advanced  condition  of  syphilograpby,  but  by  careful 
compression  of  the  text  of  previous  editions,  the  work  has  been  increased  by  only  sixty-four  pages. 
The  labor  thus  bestowed  upon  it.  it  is  hoped,  will  insure  for  it  a  continuance  of  its  position  as  a 
complete  and  trustworthy  guide  for  the  practitioner. 

It  i.s  the  most  compleiebook  with  which  we  are  ac-  ;  much  special  coramendationasif  its  predecessors  had 


quainted  in  the  language.  The  .latest  views  of  the 
best  authorities  are  put  forward,  and  tlie  information 
is  well  arranged — a  great  point  for  the  student,  and 
8till  more  for  the  practitioner.  The  subjects  of  vis- 
ceral syphilis,  syphilitic  affections  of  the  eyes,  and 
the  treatment  of  syphilis  by  repeated  inoculations,  are 
very  fully  discussed. — London  Lancet,  Jan.  7,  \^1\. 

Dr.   Burastead's   work   is  alieady  so   universally 
knuwn  as  the  best  treatise  in  the  English  language 


not  been  published.  As  a  thoroughly  practical  book 
on  a  class  of  diseases  which  form  a  large  share  of 
nearly  every  physician's  practice,  the  volume  before 
us  is  by  far  the  best  of  which  we  have  knowledge. — 
N.   Y.  Medical  Gazette.  Jan.  28,  1871. 

It  is  rare  in  the  history  of  medicine  to  find  any  one 
book  which  conlains  all  that  a  practitiouer  needs  to 
know;  while  the  possessor  of  "Bumstead  on  Vene- 
i-eal"  has  no  occasion  to  look  outside  of  its  covers  for 


venereal  diseases,  that  it  may  seem  almost  -uperflu-    anything  practical  connected  with  the  diagnosis,  his- 
ous  to  say  more  of  it  than  that  a  new  edition  has  been  '  toiy,  or  treatment  of  these  affections. — N.  Y  Medical 
issued.     But  the  author's  industry  has  renilered  this  |  Journal.  March,  1871. 
new  edition  virtually  a  new  work,  and  so  merits  as  ■ 

pULLERIER  (A.),  and  ~ 

^-^        Surgeon  to  the  Hdpital  du  Midi 


nUMSTEAD  (FREEMAN  J.), 

Professor  of  Venereal  Disea.ses  in  the  dollege  of 
Physicians  and  Sicrgeons.  N.  Y. 

AN  ATLAS  OF  VENEREAL  DISEASES.     Translated  and  Edited  by 

Freeman  J.  Bumstead.     In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 
with  26  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 
life;  strongly  bound  in  extra  cloth,  $17  00  ;  also,  in  five  parts,  stout  wrappers  for  mailing,  at 
$3  per  part.      {Lately  Published.) 
Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  Three  Dol- 
lars a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of  prac- 
tice.    Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without  delay. 
A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 
We  wish  for  once  that  our  province  was  not  restrict-     tvhich  for  its  kind  is  more  necasswr?/ for  them  to  have. 


ed  to  methods  of  treatment,  that  we  might  say  some^ 
thing  of  the  exquisite  colored  plates  in  this  volume 
— London  Practitioner,  May,  lS(i9. 

As  a  whole,  it  teaches  all  that  can  be  taught  by 
means  of  plates  and  print. — London  Lancet,  March 
13,  186fi. 

Superior  to  anything  of  the  kind  ever  before  issued 
on  this  continent. — Canada  Me'l.  Joiirnal,  March,  '69. 

The  practitioner  who  desires  to  understand  this 
branch  of  medicine  thoroughly  should  obtain  this, 
the  most  complete  and  best  work  ever  published. — 
Dominion  Med.  Jotirnal,  May,  1869. 

This  is  a  work  of  master  hands  on  both  sides.  M. 
Cullerler  is  scarcely  second  to,  we  think  we  may  truly 
say  is  a  peer  of  the  illustrious  and  venerable  Ricord, 
while  in  this  country  we  do  not  hesitate  to  say  that 
Dr.  Bumstead,  as  an  authority,  i.«  without  a  rival 
Assuring  our  readers  that  these  illustrations  tell  the 
whole  history  of  venereal  disease,  from  its  inception 
to  its  end,  we  do  not  know  a  single  medical  work, 


—California  Med.  Gazette,  March,  1869. 

The  most  splendidly  illustrated  work  in  the  lan- 
guage, and  in  our  opinion  far  more  useful  than  the 
French  original. — Am.  Journ.  Med.  Sciences,  Jan. '69. 

The  fifth  and  concluding  number  of  this  magnificent 
work  has  reached  us,  and  we  have  no  hesitation  in 
saying  that  its  illu.-trations  surpass  those  of  previous 
numbers. — Boston  Med.  and  Surg.  Journal,  Jan.  14, 
1869. 

Other  writers  besides  M.  Cullerier  have  given  us  a 
good  account  of  the  diseases  of  which  he  treats,  but 
no  one  has  furnished  us  with  such  a  complete  series 
of  illustrations  of  the  venereal  diseases.  There  is, 
however,  an  additional  interest  and  value  possessed 
by  the  volume  before  us  ;  for  it  is  an  American  reprint 
and  translation  of  M.  CuUerier's  work,  with  inci- 
dental remarks  by  one  of  the  most  eminent  American 
syphilographers,  Mr.  Bumstead. — Brit,  and  For. 
Medico-Ohir.  Review,  July,  1869. 


IF 


LL  [BERKELEY),      . 

Siirgeon  to  the  Lock  Ho.spital,  London. 

ON  SYPHILIS  AND  LOCAL  CONTAGIOUS   DISORDERS. 

one  handsome  octavo  volume  ;  extra  cloth,  $3  25.     {Lately  Published.) 


In 


Bringing,  as  it  does,  the  entire  literature  of  the  dis- 
ease down  to  the  present  day,  and  giving  with  great 
ability  the  results  of  modern  research,  it  is  in  every 
respect  a  most  desirable  work,  and  one  which  should 
find  a  place  in  the  library  of  every  surgeon. — Gali- 
fornia  Med.  Gazette,  June,  1869. 

Considering  the  scope  of  the  book  and  the  careful 
attention  to  the  manifold  aspects  and  details  of  its 


to  whom  we  would  most  earnestly  recommfind  its 
study  ;  while  it  is  no  less  useful  to  the  practitioner. — 
St.  Louis  Med.  and  Surg.  Joxirnal,  May,  1869. 

The  most  convenient  and  ready  book  of  reference 
we  have  met  with.— iV^.  Y.  Med.  Record,  May  1,1869. 

Most  admirably  arranged  for  both  student  and  prac- 
titioner, no  other  work  on  the  subject  equals  it ;  it  is 


subject,  it  is  wonderfully  concise      All  these  qualities  j  more  simple,  more  easily  studied. -^.Bw^atoJlfed.  and 
render  it  an  especially  valuable  book  to  the  beginner,  i  Surg.  Journal,  March,  1869. 


MB. 


7EISSh  [H. 

A  COMPLETE  TREATISE  OX  VENEREAL  DISEASES.  Trans- 
lated from  the  Second  Enlarged  German  Edition,  by  Frederic  R.  Sturgis,  M.D  In  one 
octavo  volume,  with  illustrations.      {Preparing.) 


20 


Heney  C.  Lea's  Publications — {Diseases  of  the  Skin). 


TJ/^ILSON  ( ERASM US),  F. R. S. 

ON  DISEASES  OF  THE  SKIN.     With  Illustrations  on  wood.    Sev- 

enth  American,  from  the  sixtli  and  enlarged  English  edition.     In  one  large  octavo  volume 
of  over  800  pages,  $5. 

A  SERIES  OF  PLATES  ILLUSTRATING  "WILSON  ON  DIS- 
EASES OF  THE  SKIN;"  consisting  of  twenty  beautifully  executed  plates,  of  which  thir- 
teen are  exquisitely  colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin, 
and  embracing  accurate  representations  of  about  one  hundred  varieties  of  disease,  most  of 
them  the  size  of  nature.     Price,  in  extra  cloth,  $5  60. 

Also,  the  Text  and  Plates,  bound  in  one  handsome  volume.     Extra  cloth,  $10. 


No  one  treating  skin  diseases  should  be  witliout 
a  copy  of  this  standard  work. —  Oanrida  Lnnce.t. 

We  can  safely  recommend  it  to  the  profession  as 
the  hest  work  on  the  suliject  now  in  existence  in 
the  English  language. — Medical  Times  and  Gazette 

Mr.  Wilson's  volume  is  an  excellent  digest  of  the 
actual  amount  of  knowledge  of  cutaneous  diseases  : 
it  includes  almost  every  fact  or  opinion  of  importance 
connected  with  the  anatomy  and  pathology  of  thf 
skin. — Brififih  and  Foreign  Medical  Review. 
,  Such  a  work  as  the  one  before  us  is  a  most  capital 

^Y  THE  SAME  AUTHOR. 


and  acceptable  help.  Mr.  Wilson  has  long  been  held 
as  high  authority  in  this  department  of  medicine,  and 
his  book  on  diseases  of  the  skin  has  long  been  re- 
garded as  one  of  the  best  text-books  extant  on  the 
subject.  The  present  edition  is  carefully  prepared, 
and  brought  up  in  its  revision  to  the  pves-ent  time  In 
chis  edition  we  have  also  included  the  beautiful  series 
of  plates  illustrative  of  the  text,  and  in  the  last  edi- 
tion published  separately.  There  are  twenty  of  these 
plates,  nearly  all  of  them  colored  to  nature,  and  ex- 
hibiting with  great  fidelity  the  various  groups  of 
diseases. — Ginainnati  Lancet. 


THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  and  Die- 

EASES  OP  THE  SKIN.    In  One  very  handsome  royal  12mo.  volume.    $3  50.    {Lately  Issued.) 


fJ'ELIGAN  {J.  MOORE),  M.D.,  M.R.I. A. 

A    PRACTICAL    TREATISE    ON    DISEASES 


OF 


Fifth  American,  from  the  second  and  enlarged  Dublin  edition  by  T. 
In  one  neat  royal  12mo.  volume  of  462  pages,  extra  cloth.     $2  25. 


THE    SKIN. 

W.  Belcher,  M.D. 


Fully  equal  to  all  the  requirements  of  students  and 
young  practitioners. — Dublin  Med.  Press. 

Of  the  remainder  of  the  work  we  have  nothing  be- 
yond unqualified  commendation  to  offer  It  is  so  far 
the  most  complete  one  of  its  size  that  has  appeared, 
and  for  the  student  there  can  be  none  which  can  com- 
pare with  it  in  practical  value.  All  the  late  disco- 
veries in  Dermatology  have  been  duly  noticed,  and 

>r   THE  SAME  AUTHOR.  — 


'.heir  value  justly  estimated  ;  in  a  word,  the  work  is 
fully  up  to  the  times,  and  is  thoroughly  stocked  with 
most  valuable  information. — New  York  Med.  Record, 
Jan.  1.5,  1867. 

The  most  convenient  manual  of  diseases  of  the 
skin  that  can  be  procurec  by  the  student. — Qhicago 
Med.  Journal,  Dec.  1866. 


B' 


ATLAS    OF    CUTANEOUS    DISEASES.      In   one   beautiful   quarto 

volume,  with  exquisitely  colored  plates,  Ac,  presenting  about  one  hundred  varieties  of 
Extra  cloth,  $5  50. 

inclined  to  consider  it  a  very  superior  work,  com- 
bining accurate  verbal  description  with  sound  views 
of  the  pathology  and  treatment  of  eruptive  diseases. 
—  Glasgow  Med.  Joxhrnal. 

A  compend  which  will-very  much  aid  the  practi- 
tioner in  this  difficult  branch  of  diagnosis  Taken 
with  the  beautiful  plates  of  the  Atlas,  which  are  re- 
markable for  their  accuracy  and  beauty  of  coloring, 
it  constitutes  a  very  valuable  addition  to  the  library 
of  a  practical  man. — Buffalo  Med.  Journal. 


disease. 
The  diagnosis  of  eruptive  disease,  however,  under 
all  circumstances,  is  very  difficult.  Nevertheless, 
Dr.  Neligan  has  certainly,  "as  far  as  possible,"  given 
a  faithful  and  accurate  representation  of  this  class  of 
di.-5eases,  and  there  can  be  no  doubt  that  these  plates 
will  be  of  great  use  to  the  student  and  practitioner  in 
drawing  a  diagnosis  as  to  the  class,  order,  and  species 
to  which  the  particular  case  may  belong.  While 
looking  over  the  "Atlas"  we  have  been  induced  to 
examine  also  the  "Practical  Treatise,"  and  we  are 


TJILLIER  {THOMAS),  M.D., 

Phy.sician  to  the  Skin  De])artment  of  University  College  Ho.spital,  &c. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 

Second  American  Edition.     In  one  royal  12mo.  volume  of  358  pp.     With  Illustrations. 
Extra  cloth,  $2  25. 

We  can  conscientiously  recommend  it  to  the  stu- 
dent;  the  style  is  clear  and  pleasant  to  read,  the 
matter  is  good,  and  the  descriptions  of  disease,  with 
the  modes  of  treatment  recommeuded,  are  frequently 
illustrated  with  well-recorded  cases. — Londo7i  Med. 
Times  and  Gazette,  April  1,  1865. 


It  is  a  concise,  plain,  practical  treatise  on  the  vari- 
ous diseases  of  the  skin  ;  just  such  a  work,  indeed, 
as  was  much  needed,  both  by  medical  students  and 
practitioners.  —  Ghieago  Medical  Examiner,  May, 
1865. 


A  NDERSON  {McCALL),  M.D., 

-^-*-  Physician  to  the  Dispensary  for  Skin  Diseases,  Glasgow,  Ac. 

ON  THE  TREATISIENT  OF  DISEASES  OF  THE  SKIN.     With  an 

Analysis  of  Eleven  Thousand  Consecutive  Cases.     In  one  vol.  8vo.     $1.     (Jiist  Hea'ly,) 


GUERSANT'S  SURGICAf.  DISEASES  OF  INFANTS 
AND  CHILDREN.  Translated  by  R.  J.  Du.ngli- 
SON,  M.D.     1  vol.  Svo.     Cloth,  $2  .")0. 


DEWEES  ON  THE  PHYSICAL  AND  MRnxrAL 
TREATMENT'  at?  OHrj.nv  w)v  Eleventh  editloa. 
I  vol.  "^vo.  of  548  pages.     $2  80. 


Henry  C.  Lea's  Publications— (Diseases  of  Children).  21 

^MITH{J.  LEWIS),  M.  D., 

^  Professor  of  Morbid  Anatomy  in  the  Bellemie  Hospital  Med.  College,  N.  T. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.     Second  Edition,  revised  nnd  greatly  enlarged.      In  one  handsome  octavo 
volume  of  742  pages,  extra  cloth,  $5;  leather,  $6.      (Jiist  Issued.) 
From  the  Preface  to  the  Second  Edition. 

In  presenting  to  the  profession  the  second  edition  of  his  work,  the  author  gratefully  acknow- 
ledges the  favorable  reception  accorded  to  the  first.  He  has  endeavored  to  merit  a  continuance 
of  this  approbation  by  rendering  the  volume  much  more  complete  than  before.  Nearly  twenty 
additional  diseases  have  been  treated  of,  among  which  may  be  named  Diseases  Incidental  to 
Biith,  Rachitis,  Tuberculosis,  Scrofula,  Intermittent,  Remittent,  and  Typhoid  Fevers,  Chorea, 
and  the  various  forms  of  Paralysis.  Many  new  formulse,  which  experience  has  shown  to  be 
useful,  have  been  introduced,  portions  of  the  text  of  a  less  practical  nature  have  been  con- 
densed, and  other  portions,  especially  those  relating  to  pathological  histology,  have  been 
rewritten  to  correspond  with  recent  discoveries.  Every  effort  has  been  made,  however,  to  avoid 
an  undue  enlargement  of  the  volume,  but,  notwithstanding  this,  and  an  increase  in  the  size  of 
the  page,  the  number  of  pages  has  been  enlarged  by  more  than  one  hundred. 

227  West  49th  Street,  New  York,  April,  1872. 

The  work  will  be  found  to  contain  nearly  one-third  more  matter  than  the  previous  edition,  and 
it  is  confidently  presented  as  in  every  respect  worthy  to  be  received  as  the  standard  American 
text-book  on  the  subject 


Emineatly  practical  as  well  as  judicious  in  its 
teachings. — Cincinnati  Lancet  and  Obs.,  July,  1S72. 

A  standard  work  that  leaves  little  to  he  desired. — 
Indiana  Journal  of  Medicine,  July,  1872. 

We  know  of  no  hook  on  this  suhject  that  we  can 
more  cordially  recommend  to  the  medical  stiideut 
and  the  practitioner. — Cincinnati  Clinic,  June29,  '72. 


We  regard  it  as  superior  to  any  other  single  woi'k 
on  the  diseases  of  iuf;iiicy  and  childhood. — Detroit 
Bev.  of  Med.  and  Pharnuicy,  Aug.  1&72. 

We  confess  to  increased  enthusiasm  in  recommend- 
ing this  second  edition. — St  Louis  Med.  and  Surg. 
Journal,  Aug.  1S72. 


ftONDIE  [D.  FRANCIS),  31.  D. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN. 

Sixth  edition,  revised  and  augmented.     In  one  large  octavo  volume  of  nearly  800  closely- 
printed  pages,  extra  cloth,  $5  25;  leather,  $6  25.       {Lately  Issjied.) 
The  present  edition,  which  is  the  sixth,  is  fully  up  1  teachers.     As  a  whole,  however,  the  work  is  the  best 
to  the  times  in  the  discussion  of  all  those  points  in  the  |  American  one  that  we  have,  and  in  its  special  adapta- 
pathology  and  treatment  of  infantile  diseases  which  I  tion  to  American  practitioners  it  certainly  has   no 
havebeenbroughtforwardhytheGermauand  French  |  equal.  —  New  York  Med.  Record,  March  2,  1S68. 


T^EST  [CHARLES),  M.D., 

'  '  Physician  to  the  Hospital  for  Sick  Children,  &c. 

LECTURES  ON   THE   DISEASES   OF   INFANCY  AND  CHILD- 

HOOD.     Fifth  American  from  the  sixth  revised  and  enlarged  English  edition.     In  one  large 
and  handsome  octavo  volume  of  678  pages.     Cloth,  $4  60  ;  leather,  $6  50.      {Just  Ready.) 

The  continued  demand  for  this  work  on  both  sides  of  the  Atlantic,  and  its  translation  into  Ger- 
man, French,  Italian,  Danish,  Dutch,  and  Russian,  show  that  it  fills  satisfactorily  a  want  exten- 
sively felt  by  the  profession.  There  is  probably  no  man  living  who  can  speak  with  the  authority 
derived  from  a  more  extended  experience  than  Dr.  West,  and  his  work  now  presents  the  results  of 
nearly  2000  recorded  cases,  and  600  post-mortem  examinations  selected  from  among  nearly  40,000 
cases  which  have  passed  under  his  care.  In  the  preparntion  of  the  present  edition  he  has  omitted 
much  that  appeared  of  minor  importance,  in  order  to  find  room  for  the  introduction  of  additional 
matter,  and  the  volume,  while  thoroughly  revised,  is  therefore  not  increased  materially  in  size. 

Of  all  the  English  writers  on  the  diseases  of  chil-  I  living  authorities  in  the  difficult  department  of  medi- 
dren,  there  is  no  one  so  entirely  satisfactory  to  us  as  |  cal  science  in  which  he  is   most  widely  known. — 
Dr.  West.    For  years  we  have  held  his  opinion  as  I  Boston  Med.  and  Surg.  Journal. 
judicial,  and  have  regarded  him  as  one  of  the  highest  | 

or  THE  SAME  AUTHOR.    {Lately Issued.) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 

HOOD;  being  the  Lumleian  Lectures  delivered  at  the  Royal  College  of  Physicians  of  Lon- 
don, in  March,  1871.     In  one  volume,  small  12mo.,  extra  cloth,  $1  00. 

^MITH  [E USTA  CE),  M.  D., 

Physician  to  the  Northwe.st  London  Free  Dispensary  for  Sick  Children. 

A  PRACTICAL  TREATISE  ON   THE  WASTING   DISEASES  OF 

INFANCY  AND  CHILDHOOD.     Second  American,  from  the  second  revised  and  enlarged 
English  edition.     In  one  handsome  octavo  volume,  extra  cloth,  $2  50.      {Lately  Issued.) 

scribed  as  a  practical  handbook  of  the  common  dis- 
eases of  children,  so  numerous  are  the  affections  con- 
sidered either  collaterally  or  directly  We  are 
acquainted  with  no  safer  guide  to  the  treatment  of 
children's  diseases,  and  few  works  give  the  insight 
into  the  physiological  and  other  peculiarities  of  chil- 
dren that  Dr.  Smith's  book  does. — Brit.  Med.  Journ., 
April  8,  1871. 


This  is  in  every  way  an  admirable  book.  The 
modest  title  which  the  author  has  chosen  for  it  scarce- 
ly conveys  an  adequate  idea  of  the  many  subjects 
upoQ  which  it  ti'eats.  Wasting  is  so  constant  an  at- 
tendant upon  the  maladies  of  childhood,  that  a  trea- 
tise upon  the  wasting  diseases  of  children  must  neces 
sarily  embrace  the  consideration  of  many  affections 
of  which  it  is  a  symptom  ;  and  this  is  excellently  well 
done  by  Dr.  Smith.    The  book  might  fairly  be  de- 


Henry  C.  Lea's  Publications — (Diseases  of  Women). 


rpHE  OBSTETRICAL  JOURNAL. 

THE    OBSTETRICAL    JOURXAL    of  Great   Britain    and  Ireland; 

Including  Midwifery,  nnd  the  Diseases  of  Women  and  Infants.  With  an  American 
Supplement,  edited  by  William  F.  Jenks.  M.D.  A  monthly  of  about  80  octavo  pages, 
very  handsomely  printed.  Subscription,  Five  Dollars  per  annum.  Single  Numbers,  50 
cents  each. 

Commencing  with  April,  187.S,  the  Obstetrical  Journal  consists  of  Original  Papers  by  Brit- 
ish and  Foreign  Contributors  :  Tninsaetions  of  the  Obstetrical  Societies  in  England  and  abroad  ; 
Reports  of  Hospital  Practice:  Reviews  and  Bibliographical  Notices;  Articles  and  Notes,  Edito- 
rial, Historical,  Forensic,  and  Miscellaneous;  Selections  from  Journals;  Correspondence,  <fec. 
Collecting  together  the  vast  amount  of  material  daily  accumulating  in  this  important  and  ra- 
pidly improving  department  of  medical  science,  the  value  of  the  information  which  it  pre- 
sents to  the  subscriber  may  be  estimated  from  the  character  of  the  gentlemen  who  have  alre:idy 
promised  their  support,  including  such  names  as  those  of  Drs.  Atthill,  Robert  Barnes,  Henry 
Bennet,  Thomas  Chambers,  Flef.twood  Churchill,  Matthews  Ddncan,  Graily  Hewitt, 
Braxton  Hicks,  Alfred  Meadows,  W.  Leishman,  Alex.  Simpson,  Tyler  Smith,  Edward  J. 
Tilt,  Spencer  Wells,  <fec.  &e.  ;  in  short,  the  representative  men  of  British  Obstetrics  and  Gynae- 
cology. 

In  order  to  render  the  Obstetrical  Journal  fully  adequate  to  the  wants  of  the  American 
profession,  each  number  contains  a  Supplement  devoted  to  the  advances  made  in  Obstetrics  and 
Gynaecology  on  this  side  of  the  Atlantic.  This  portion  of  the  Journal  is  under  the  editorial 
charge  of  Dr.  William  F.  Jenks,  to  whom  editorial  communications,  exchanges,  books  for  re- 
view, &e.,  may  be  addressed,  to  the  care  of  the  publisher. 

*.'.*  Complete  sets  from  the  beginning  can  no  longer  be  furnished,  but  subscriptions  can  com- 
mence with  January,  1874,  or  with  Vol.  II.,  April,  1874. 


/THOMAS  [T.  GAILLARD).3I.D., 

-*•  Professor  of  Obstetrics,  S:c..  in  the  College  of  Physicians  and  Surgeons,  N.  T.,  &e. 

A  PRACTICAL  TREATISE  OX  THE  DISEASES  OF  WOMEN.    Third 

edition,  enlarged  and  thoroughly  revised.     In  one  large  and  handsome  octavo  volume  of 
784  pages,  with  246  illustrations.     Cloth,  $5  00;  leather,  S6  00.     {Lately  Issued.) 

The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  another  edition  of 
this  work  to  render  it  worthy  a  continuance  of  the  very  remarkable  favor  with  which  it  has  been 
received.  Every  portion  has  been  subjected  to  a  conscientious  revision,  several  new  chapters 
have  been  added,  and  no  labor  spared  to  make  it  a  complete  treatise  on  the  most  advanced  con- 
dition of  its  important  subject.  The  present  edition  therefore  contains  about  one-third  more 
matter  than  the  previous  one,  notwithstanding  which  the  price  has  been  maintained  at  the  former 
very  moderate  rate,  rendering  this  one  of  the  cheapest  volumes  accessible  to  the  profession. 

As  compared  with  the  fir.st  edition,  five  new  chap-  We  are  free  to  .«ay  that  we  regard  Dr  Thomas  the 
tevs  on  dysmenorrhoea,  peri-uterine  fluid  tumors,  best  American  authority  on  dlseasesof  women.  Seve- 
composite  tumors  of  the  ovary,  solid  tumors  of  the  ral  others  have  ivritten.  and  written  well,  but  none 
ovary,  and  chlorosis,  have  been  added.  Twenty- 
seven  additional  woodcuts  have  been  introduced, 
many  subjects  have  been  subdivided,  and  all  have 
received  imponant  interstitial  increase  In  fact,  llie 
book  has  been  practically  rp\vrittpn,  and  greatly  in- 
creased in  value  Briefly,  we  may  say  thai  we  know 
of  no  book  which  so  completely  and  concisely  repie- 
sents  the  present  state  of  gynecology  :  none  so  full 
of  well-digested  and  reliable  teachfijg ;  nmie  which 
bespeaks  an  author  more  apt  in  research  and  abun- 
dant in  resources. — A  Y  Med.  Record,  May  1,  1  S72. 
We  should  not  be  doing  our  duty  to  the  profe-ssion 
did  we  not  tell  those  who  are  unacquainted  with  the 
book,  how  much  it  is  valued  by  gynecologists,  and 
how  it  is  in  many  respects  one  of  the  best  text-bnoks 
on  the  subject  we  possess  in  our  language  We  have 
no  he.silationin  recommending  Dr.  Thomas's  work  a.- 
one  of  the  most  complete  of  its  kind  ever  publishpd 
It  should  be  in  the  possession  of  every  practitioner 
for  reference  and  for  stadj.  — London  Layieet,  April 
27,  1S72. 


Our  author  is  not  one  of  those  whose  views  ' '  never 
change."  On  the  contrary,  tliey  have  been  modified 
in  m.'iny  particulars  to  accord  with  the  progress  made 
in  this  department  of  medical  science:  hence  it  has  the 
fresh aess  of  an  entirely  new  work.  Xo  general  piac- 
tinoner  can  afford  to  be  without  it. — St.  Louis  Med 
and  Sv.rg  Journal,  May,  IS72. 

Usable  author  need  not  fear  compHrison  between 
it  and  any  similar  work  in  the  English  language; 
nay  more,  as  a  text  book  for  students  and  as  a  guide 
for  practitioners,  we  believe  it  is  unequalled.  In  the 
libraries  of  reading  physicians  we  meet  with  it 
of  finer  than  a  ny  other  treatise  on  diseases  of  women. 

We.oncludeourbriefreview  by  repeatingihe  heany  the  first  edition  of  this  boob,  that  we  deem  it  only 
couiinenda'ion  of  tbis  volume  gi^en  when  we  com-  necessary  now  to  call  attention  to  the  second  appear- 
menced  :  if  either  student  or  practitioner  ""an  get  but  ance  of  the  work.  Its  success  has  been  remarkable, 
one  book  on  diseases  of  wom^n  that  book  should  be  and  we  cau  only  congratulate  the  aulhor  on  the 
"Thomas."  —  AmtT.  Jour.  Med.  Scitnceti,  April,  brilliant  reception  his  book  has  received. — N.Y.Med. 
1872.  I  Journal,  April,  1S69. 


have  so  clearly  ani  carefully  arranged  their  text  a  nd 
ins. ruction  as  Dr.  Thomas. — Cincinnati  Lancet  and 
Observer,  May,  1872. 

We  deem  it  scarcely  necessary  to  recommend  this 
work  to  physicians  as  it  is  now  widely  known,  and 
most  of  them  already  possess  it,  or  will  certainly  do 
so.  To  siudents  we  unhesitatingly  recommend  it  as 
the  best  text-book  on  disea.ses  of  females  extant, — St. 
Loii.if  Med.  Reporter,  June.  1869. 

Of  all  the  army  of  books  that  have  appeared  of  late 
years,  on  the  di. -ceases  of  the  uterus  and  its  appendages, 
we  know  of  none  that  is  so  clear,  cotnprehensive,  and 
practical  a-  this  of  Dr.  Thomas',  or  one  that  we  should 
more  em;  latically  recommend  to  the  young  practi- 
tioner, as  his  guide. — California  Med.  Gazette,  June. 

If  not  the  best  work  extant  on  the  subject  of  which 
it  treats,  it  is  certaiuly  second  to  none  other.  So 
short  a  time  has  elapsed  since  the  medical  press 
teemed  with  commendatory  notices  of  the  first  edition, 
that  it  would  be  superfluous  to  give  an  expended  re- 
view of  what  is  now  firmly  established  as  f/j«  American 
text-book  of  Gynaecology. — N.  Y.  Med.  Gazette,  July 

17,  ise.q. 

This  is  a  new  and  revised  edition  of  a  work  which 
we  recently  noticed  at  some  length,  and  earnestly 
commended  to  the  favorable  attentiou  of  our  readers. 
The  fact  that,  in  the  short  space  of  one  year,  this 
second  edition  makes  its  appearance,  shows  that  the 
general  judgment  of  the  profession  has  largely  con- 
firmed tiie  opinion  we  gave  at  that  time. — Cincinnati 
Lancet,  Aug.  1869. 

It  is  so  short  a  time  since  we  gave  a  full  review  of 


Henry  C.  Lea's  Publications — (Diseases  of  Women). 


H' 


ODGE  {HUGH  L.),  M.D., 

Eraeritus  Professor  of  Obstetrics,  d-e.,  in  the  Uviversity  nf  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN;  including  Displacements 

of  the  Uterus.     "With  original  illustrations.     Second   edition,  revised  and  enlarged.     In 
one  beautifully  printed  octavo  volume  of  531  pages,  extra  cloth.     $4  50.     [Lately  Issusd.) 

:hat  ■which  speaks  of  the  mechanical  treatment  of  dis- 
placements of  that  organ.  He  is  disposed,  as  a  non- 
■>Rliever  in  the  fveqnency  of  ioHammations  of  the 
aterns,  to  take  strong  ground  against  many  of  tha 
highest  authorities  in  this  branch  of  medicine,  and 
the  arguments  which  he  offers  in  support  of  his  posi- 
tion are,  to  say  the  least,  well  put.  Numerous  wood- 
cuts adorn  this  portion  of  the  work,  and  add  incalcu- 
lably to  the  proper  appreciation  of  the  variously 
shaped  instruments  referred  to  by  our  author.  As  a 
contribution  to  the  study  of  women's  diseases,  it  is  of 
great  valtre,  and  is  abundantly  able  to  stand  on  its 


From  Prof.  W.  H.  Btford,  of  the  R-n^h  Medical 
College,  Chicago. 

The  book  bears  the  impress  of  a  master  hand,  and 
must,  as  its  predecessor,  prove  acceptable  to  the  pro- 
fession. In  diseases  of  women  Dr.  Hodge  has  estab- 
lished a  school  of  treatment  that  has  become  -world- 
ivide  in  fame. 

Professor  Hodge's  work  Is   truly  an  original  one 


from  beginniog  to  end,  consequently  no  one  can  pe 
ruse  itspagei^without  learning  something  new.    The 

book,  which  is  by  no  means  a  large  one,  is  divided  into       _^ 

two  grand  secti.-jns,  so  to  speak  :  first,  that  treating  of  1  q.^^^  merits.' — N.  Y.  Medical  Record,  Sept.  15,  1868. 
the  nervous  sympathies  of  the  uterus,  and,  secondly. 


'W'EST  (CHARLES),  M.D. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.    Third  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  550  pages,  extra 

cloth,    $3  75  ;  leather,  $4  76. 

seeking-truth,  and  one  that  will  convince  the  student 
that  he  has  committed  himself  to  a  candid,  safe,  and 


As  a  writer.  Dr.  West  staaUs,  in  our  opinion,  se- 
cond only  to  Watson,  the  "Macaulay  of  Jledicine;' 
he  possesses  that  happy  faculty  of  clothing  instrnc 
tion  in  easy  garments ;  combining  pleasure  with 
profit,  he  leads  his  pupils,  in  spite  of  the  ancient  pro 
verb,  along  a  royal  road  to  learning.  His  work  is  one 
which  will  not  satisfy  the  extreme  on  either  side,  but 
it  is  one  that  will  please  the  great  majoi'ity  who  art 


valuable  guide. —i^''.  A.  Med.-Chiru.rg  Review. 

We  have  to  say  of  it,  briefly  and  decidedly,  that  it 
is  the  best  work  on  the  subject  in  any  language,  and 
that  it  stamps  Dr.  West  as  the  facile  princeps  of 
British  obstetric  authors. — Edinburgh  Med.  Journal. 


B 


ARNES  (ROBERT),  31.  D.,  F.R.G.P., 

OhRfetrie  Physician  tn  St.  Thorna.'i's  Hospital,  &c. 

A  CLINICAL  EXPOSITION  OF  THE  MEDICAL  AND  SURGI- 
CAL DISEASES  OF  WOMEN.  In  oT,e  handonme  onta.vn  -trolnme  of  about  800  pages,  with 
lfi9  illustrations.      Cloth.  $5   00,   leather,  $6  00.      (Just  Rmdy.^ 

The  very  complete  scope  of  this  volume  and  the  manner  in  which  it  has  been  filled  out,  may 
be  seen  by  the  subjoined  Sumaiary  of  Contents. 

Intboduction.  Chapter  I.  Ovnries  ;  Corpus  Luteum.  II.  Fallopian  Tubes.  III.  Shape  of 
Uterine  Cavity.  IV.  Structure  of  Uterus.  V.  The  Vagina.  VI.  Examinations  and  Diagnosis. 
VII.  Significance  nf  Lencorrhoea.  VTII.  Discharges  of  Air.  IX.  Watery  Discharges.  X.  Puru- 
lent Discharges.  XI.  Hemorrhagic  Di.=oharges.  XII  Significance  of  Pain.  XIII.  Significance 
of  Dyspareunia.  XIV.  Significance  of  Sterility.  XV.  Instrumental  Diagnosis  and  Treatment. 
XVI.  Diagnosis  by  the  Touch,  the  Sound,  the  Speculum.  XVII.  Menstruation  and  its  Disor- 
ders. XVIII.  Amenorrhcea.  XIX.  Amennrrboea  (continued).  XX.  Dysmenorrhoea.  XXI. 
Ovarian  Dysmenorrhoea.  <tc.  XXII.  Inflammatory  Dysmenorrhoea.  XXIII  Irregularities  of 
Change  of  Life.  XXIV.  Relation?  between  Men.struation  and  Diseases.  XXV.  Disorders  of  Old 
Age.  XXVI.  Ovary,  Absence  and  Hernia  of.  XXVII.  Ovary,  Hemorrhage,  Ac,  of.  XXVIII. 
Ovary,  Tubercle,  Cancer,  ka  ,  of  XXIX.  Ovarian  Cystic  Tumors.  XXX.  Dermoid  Cysts  of 
Ovary.  XXXI.  Ovarian  Tumors,  Prognosis  of.  XXXTI.  Diagnosis  of  Ovarian  Tumors.  XXXIII. 
Ovarian  Cysts,  Treatment  of.  XXXIV.  Fallopian  Tubes.  Diseases  of.  XXXV.  Broad  Liga- 
ments, Diseases  of.  XXXVI.  Extra-uterine  Gestation.  XXXVII.  Special  Pathology  of  Ute- 
rus. XXXVIII  Genera]  Uterine  Pathology.  XXXIX  Alterations  of  Blood  Supply.  XL. 
Metritis.  Endometritis,  &c.  XLI.  Pelvic  Cellulitis  and  Peritonitis,  A'c.  XLIL  Hematocele,  &c. 
XLIII.  Displacements  of  Uterus.  XLIV.  Displacements  (continued).  XLV.  Retroversion  and 
Retroflexion.  XLVI.  Inversion.  XLVII.  Uterine  Tumors.  XLVIII.  Polypus  Uteri.  XLIX. 
Polypus  Uteri  (continued).     L.   Cancer.     LI.  Diseases  of  Vagina.     LII.   Diseases  of  the  Vulva. 


Embodyingthelongexperience  and  personal  obser- 
vation of  one  of  the  greatest  of  living  teachers  in  dis- 
eases of  women,  it  seems  pervaded  by  the  presence 
of  the  author,  who  speaks  directly  to  the  reader,  and 
speaks,  too,  as  one  having  authority.  And  yet,  not- 
withstanding this  distinct  personality,  there  is  noth- 
ing narrow  as  to  time,  place,  or  individuals,  in  the 
views  presented,  and  in  the  in-Structions  given;  Dr. 
Barnes  has  been  an  attentive  student,  not  only  of  Eu- 
ropean, but  also  of  American  literature,  pertaining  to 
diseases  of  females,  and  enriched  his  own  experience 
by  treasures  thence  gathered  ;  he  seems  as  familiar, 
for  example,  with  the  writings  of  Sims,  Emmet,  Tho. 


mas,  and  Peaslee,  as  if  these  eminent  men  were  his 
countrymen  and  colleagues,  and  gives  them  a  credit 
which  "must  be  gratifving  to  every  American  physi- 
cian.— Am   Journ.  Med.  Sei  ,  April,  1S74. 

Throughout  the  whole  book  it  is  impossible  not  to 
feelthat  theaulhor  has  spontaneously,  conscientious- 
ly, and  fenrlessly  performed  his  task.  He  goes  direct 
to  the  point,  and  does  not  loiter  on  the  way  to  gossip 
or  quarrel  with  other  authors.  Dr.  Barnes's  book 
will  be  eagerly  rend  all  over  the  world,  and  will 
everywhere  be  admired  for  its  comprehensiveness, 
honesty  of  purpose,  and  ability  — The  Obstet.  Journ. 
nf  Great  Britain  and  Ireland,  March,  lS7i. 


CHURCHILL  0N\'HE  PUERPERAL  FEVER  AND 
OTHER  DISEASES  PECULIAR  TO  WOMEN.  1  vol. 
8vo.,  pp.  4.50,  extra  cloth.     S'2  50. 

DEWEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES. With  illustrations.  Eleventh  Edition 
with  the  Author's  last  improvements  and  correc 
tions.  In  one  octavo  volume  of  .536  uages,  with 
plates,  extra  cloth.     ^^  on. 

WEST'S  ENQUIRY  INTO  THE  PATHOLOGICAL 
I.Ml'ORTANCE  OF  ULCERATION  OF  THE  OS 
UTEKI.     i  vol.  bvo.,  extra  cloth,     sjil  25. 


MEIGS  ON  WOMAN:  HER  DISEASES  AND  THEIR 
REMEDIES  A  Series  of  Lectures  to  his  Class. 
Fourth  and  Improved  Edition.  1  vol.  Svo.,  over 
700  pages,  extra  cloth,  iiio  00  ;  leather,  .$6  00. 

MEIGS  ON  THE  NATURE,  SIGNS,  AND  TREAT- 
MENT OF  CHILDBED  FEVER.  1  vol.  Svo.,  pp. 
.36.5,  extra  cloth.     $2  00. 

ASHWELL'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES PECULIAR  TO  WO.MEN.  Third  American, 
from  the  Third  and  revised  Lnndon  edition.  1  vol. 
Svo.,  pp.  52S,  extra  cloth.    $3  50. 


24 


Henry  C.  Lea's  Publications — {Midwifery). 


ffODGE  [HUGH  L.),  M.D., 

-'■-'-  Emeritus  Professor  of  Midwifery,  &e  ,  in  the  University  of  Pennsylvania,  &c. 

THE    PRINCIPLES  AND   PRACTICE   OF   OBSTETRICS.     Illus- 

trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 

original  photographs,  and  with  numerous  wood-cuts.     In  one  large  and  beautifully  printed 

quarto  volume  of  550  double-columned  pages,  strongly  bound  in  extra  cloth,  $14. 

The  work  of  Dr.  Hodge  is  something  more  than  a,\      We  ha-ve  examined  Professor  Hodge's  work  with 

simple  presentation  of  his  particular  views  in  the  de-  great  satisfaction;    every   topic  is  elaborated   most 

partment  of  Obstetrics;  it  is  something  more  than  an j fully.     The  views  of  the  author  are  comprehensive, 

ordinary  treatise  on  midwifery;  it  is,  in  fact,  a  cyclo-land  concisely  stated.     The  rules  of  practice  are  judi- 

psedia  of  midwifery.     He  has  aimed  to  embody  in  a  cious,  and  will  enable  the  practitioner  to  meet  every 


single  volume  the  whole  science  and  art  of  Obstetrics. 
An  elaboiate  text  is  combined  with  accurate  and  va- 
ried pictorial  illustrations,  so  that  no  fact  or  principle 
Is  left  unstated  or  unexplained. — Atti.  Med.  Times, 
Sept.  3,  1S64. 

We  should  like  to  analyze  the  remainder  of  this 
excellent  work,  but  already  has  this  review  extended 
beyond  our  limited  space.     We  cannot  conclude  this 

aotice  without  referring  to  the  excelleni  finish  of  the  ^;^   ^,^^  ^  Journal,  July,  1864. 

work.     In  typography  it  is  not  to  be  excelled ;  the  "  >         j  > 

paper  is  superior  to  what  is  usually  afforded  by  our 
American  cousins,  quite  equal  to  the  best  of  English 
books.     The  engravings  and    lithographs   are  most 


emergency  of  obstetric  complication  with  confidence 
— Chicago  Med.  Journal,  Aug.  1S64. 

More  time  than  we  have  had  at  our  disposal  since 
we  received  the  great  work  of  Dr.  Hodge  is  necessary 
to  do  it  justice.  It  is  undoubtedly  by^ar  the  most 
original,  complete,  and  carefully  composed  treatise 
on  the  principles  and  practice  of  Obstetrics  which  has 
ever  been  issued  from  the  American  press. — Pacific 


We  have  read  Dr.  Hodge's  book  with  great  plea- 
sure, and  have  much  satisfaction  in  expressing  our 
commendation  of  it  as  a  whole.    It  is  certainly  highly 


beautifully  executed.     The  work  recommends  itselfna^tructive,  and  in  the  main,  we  believe,  correct.   The 


for  its  originality,  and  is  in  every  way  a  most  valu- 
able addition  to  those  on  the  subject  of  obsteti'ics 
Canada  Med.  Journal,  Oct.  1864. 


great  attention  which  the  author  has  devoted  to  the 
mechanism  of  parturition,  taken  along. with  the  con- 
clusions at  which  he  has  arrived,  point,  we  think, 


It  is  very  large,  profusely  and  elegantly  illustrated,   conclusively  to  the  fact  that,  in  Britain  at  least,  the 
and  is  fitted  to  take  its  place  near  the  works  of  great  doctrines  of  Naegele  have  been  too  blindly  received, 
obstetricians.    Of  the  American  works  on  the  subject  i — Glasgow  Med.  Journal,  Oct.  1864. 
It  is  decidedly  the  best. — Edinb.  Med.  Jour.,  Dec.  '64  I 

#**  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mail, 
on  receipt  of  six  cents  in  postage  stamps. 

JIANNER  [THOMAS  H.),  M.D. 
ON  THE  SIGNS  AND  DISEAvSES  OF  PREGNANCY.     First  American 

from  the  Second  and  Enlarged  English  Edition.     With  four  colored  plates  and  illustrations 
on  wood.     In  one  handsome  octavo  volume  of  about  600  pages,  extra  cloth,  $4  25. 

The  very  thorough  revision  the  work  has  undergone 
has  added  greatly  to  its  practical  value,  and  increased 


materially  its  efliciency  as  a  guide  to  the  student  and 
to  the  young  practitioner. — Am.  Journ.  Med.  Sei., 
April,  1868. 

With  the  immense  variety  of  subjects  treated  of 
and  the  ground  which  they  are  made  to  cover,  the  im- 
possibility of  giving  an  extended  review  of  this  truly 
remarkable  work  must  be  apparent.  We  have  not  a 
single  fault  to  find  with  it,  and  most  heartily  com- 
mend it  to  the  careful  study  of  every  physician  who 
would  not  only  always  be  sure  of  his  diagnosis  of 


pregnancy,  but  always  ready  to  treat  all  the  nume- 
rous ailments  that  are,  unfortunately  for  the  civilized 
tvomen  of  to-day,  so  commonly  associated  with  the 
function. — N.  Y.  Med.  Record,  March  16   1868. 

We  recommend  obstetrical  students,  young  and 
old,  to  hav(  this  volume  in  their  collections.  It  con 
tains  not  onl  3  a  fair  statement  of  the  .signs,  symptoms, 
and  diseases  of  pregnancy,  but  comprises  in  addition 
much  interesting  relative  matter  that  is  not  to  be 
found  in  anj  other  work  that  we  can  name. — Edin- 
burgh Med  Journal,  Jan.  ISbS. 


8 


WAFNE  [JOSEPH  GRIFFITHS),  M.  D., 

Physician-Accoucheur  to  the  British  General  Hospital,  &c. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 
MENCING MIDWIFERY  PRACTICE.     Second  American,  from  the  Fifth  and  Revised 
London  Edition,  with  Additions  by  E.  R.  Hutchins,  M.  D.     With  Illustrations.     In  one 
neat  12mo.  volume.     Extra  cloth,  $1  25.      (Now  Ready.) 
* .  *  See  p.   3  of  this  Catalogue  for  the  terms  on  which  this  work  is  offered  as  a  premium   to 
subscribers  to  the  "American  Journal  op  the  Medical  Sciences." 

it  IS  really  a  capital  little  compendium  of  the  sub-  answers  the  purpose.  It  is  not  only  valuable  for 
Ject,  and  we  recommend  young  practitioners  to  buy  it '  young  beginners,  but  no  one  who  is  not  a  proficient 
and  carry  it  with  them  when  called  to  attend  cases  of  I  in  the  art  of  obstetrics  should  be  without  it,  because 


labor.  They  can  while  away  the  otherwise  tedious 
hours  of  waiting,  and  thoroughly  fix  in  their  memo- 
ries the  most  important  practical  suggestions  it  cen- 
tal us.  The  American  editor  has  materially  added  by 
his  no'tes  and  the  concluding  chapters  to  the  com- 
pleteness and  general  value  of  the  book. — Chicago 
Med.  Journal,  Feb.  1870. 

The  manual  before  us  containsin  exceedingly  small 
compass — small  enough  to  carry  in  the  pockei, — about 
all  I  here  is  of  obstetrics,  condensed  into  a  nutshell  of 
Aphorisms.  The  illustrations  are  well  selected,  and 
serve  as  excellent  reminders  of  the  conduct  of  labor — 
regular  and  difficult. — Cincinnati  Lancet,  April,  '70. 

""h'::  Ib  a  moBtadmirablelittle  work, and  completely 


it  condenses  all  that  is  necessary  to  know  for  ordi- 
nary midwifery  practice.  We  commend  the  book 
most  favorably. — St.  Louis  Med.  and  Surg.  Journal, 
Sept.  10,  1870. 

A  studied  perusal  ,of  this  little  book  has  satisfied 
us  of  its  eminently  practical  value.  The  object  of  the 
work,  the  author  says,  in  his  preface,  is  to  give  the 
student  a  few  brief  and  practical  directions  respect- 
ing the  management  of  ordinary  cases  of  labor ;  and 
also  to  point  out  to  him  in  extraordinary  cases  whea 
and  how  he  may  act  upon  his  own  re-ponsibility,  and 
when  he  ought  to  send  for  a8sisti4^e. — N.  T.  Medial 
Journal,  May,  1870. 


\TINCKEL  [F.), 

Professor  and  Director  of  the  Gynacological  Clinic  in  the  University  of  Rostock. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 
MENT OF  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent  of 
the  author,  from  the  Second  German  Edition,  by  James  Read  Chadwick,  M  D.  In  one 
octavo  volume.      {Preparing.) 


Henry  C.  Lea's  Publications — {Midwifery). 


TEISHMAN  [WILLIAM),  M.D., 

Regius  Professor  of  lliiJwifery  in  the.  Universi'y  of  Glasgoie,  &c. 

A  SYSTEM  OF  MIDWIFERY,  INCLUDING  THE  DISEASES  OF 

PREGNANCY  AND  THE  PUERPERAL  STATE.  In  one  large  and  very  handsome  oc- 
tavo volume  of  over  700  pages,  with  one  hundred  and  eighty-two  illustrations.  Cloth, 
$5  00  ;  leather,  $6  00.      {Now  Ready.) 

"A  Complete  System  of  the  Midwifery  of  the  Present 
Day,"  and  well  redeems  the  promise.  In  all  that 
relates  to  the  subject  of  labor,  the  teaching  is  admi- 
rably clear,  coucise,  aud  practical,  representing  not 
alone  British  practice,  but  the  contributions  of  Con- 
tinental and  American  schools. — N.  Y.  Mtd.  Record, 
March  2,  1S74. 


This  is  one  of  a  most  complete  aud  exhaustive  cha- 
racter. We  have  gon?  carefnlly  through  it, 'and  there 
is  no  subject  in  Obstetrics  which  has  not  been  con- 
sidered well  and  fully.  The  result  is  a  work,  not 
only  admirable  as  a  text-book,  but  valuable  as  a  work 
of  reference  to  the  practitioner  in  the  various  emer- 
gencies of  obstetric  practice.  Take  it  all  in  all,  we 
have  no  hesitation  in  saying  that  it  is  in  our  judgment 
the  best  English  work  on  the  subject. — London La7i- 
cet,A\\g.  2.:i,  187.3. 

The  work  of  Leishman  gives  an  excellent  view  of 
modern  midwifery,  and  evinces  its  author's  extensive 
acquaintance  with  British  and  foreign  literature  ;  and 
not  only  acquaintance  with  it,  but  wholesome  diges- 
tion and  sound  judgment  of  it.  He  has,  withal,  a 
manly,  free  style,  and  can  state  a  difficult  and  compli- 
cated matter  with  remarkable  clearness  and  bi'evity. 
— Kdin.  Med.  Journ.,  Sept.  1873. 

The  author  has  succeeded  in  presenting  to  the  pro- 
fession an  admirable  treatise,  especially  in  its  practi- 
cal aspects  ;  one  which  is,  in  general,  clearly  written, 
and  sound  in  doctrine,  and  one  which  cannot  fail  to 
add  to  his  already  high  reputation.  In  concluding 
our  examination  of  this  work,  we  cannot  avoid  again 
saying  that  Dr.  Leishman  has  fully  accomplished 
that  difficult  task  of  presenting  a  good  text-book  upon 
obstetrics.  We  know  none  better  for  the  use  of  the  stu- 
dent or  junior  practitioner. — Am.  PrUctitioner,  Mar. 
1874. 

It  proposes  to  offer  to  practitioners  and  students 


The  work  of  Dr.  Leishman  is,  in  many  respects, 
not  only  the  best  treatise  on  midwifery  that  we  hHve 
seen,  but  one  of  the  best  treatises  on  any  medical  sn  In- 
ject that  has  beeu  published  of  late  years. — Lond. 
Practitioner,  Feb.  187-1:. 

It  was  written  to  supply  a  desideratum,  and  we  will 
be  much  surprised  if  it  does  not  fulfil  the  purpose  of 
its  author.  Takiug  it  as  a  whole,  we  know  of  no 
work  on  obstetrics  by  an  English  authorin  whichthe 
student  and  the  practitioner  will  find  theinformati>in 
so  clear  and  so  completely  abi  east  of  the  present  stale 
of  our  knowledge  on  the  svLb]%ci.~ Glasgow  Med. 
Journ.,  Aug.  1873. 

Dr.  Leishman's  System  of  Midwifery,  which  has 
only  just  been  published,  will  go  far  to  supply  the 
want  which  has  so  long  been  felt,  of  a  really  good 
modern  English  text-book.  Although  large,  as  is  in- 
evitable in  a  work  on  so  extensive  a  subject,  it  is  so 
well  and  clearly  written,  that  it  is  never  wearisome 
to  read.  Dr.  Leishman's  work  maybe  confidently 
recommended  as  an  admirable  text-book,  and  is  sure 
to  be  ItU-gely  used.— Lojid.  Med.  Record,  Sept.  1873. 


UAMSBOTHAM  [FRANCIS  H.] 


D. 


THE  PRINCIPLES   AND    PRACTICE    OF   OBSTETRIC  MEDL 

CINE  AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  &c.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  large 
and  handsome  imperial  octavo  volume  of  6,50  pages,  strongly  bound  in  leather,  with  raised 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.     $7  00. 

To  the  physician's  library  it  is  indispensable,  while 
to  the  student,  as  a  text-book,  from  which  to  extract 
the  material  for  laying  the  foundation  of  an  education 
on  obstetrical  science,  it  has  no  superior. — Ohio  Med. 
and  Surg.  Journal. 

When  we  call  to  mind  the  toil  we  underwent  in 
acquiring  a  knowledge  of  this  subject,  we  cannot  but 
envy  the  student  of  the  present  day  the  aid  which 


We  will  only  add  that  the  student  will  learn  from 
!t  all  he  need  to  know,  and  the  practitioner  will  find 
It,  as  a  book  of  reference,  surpassed  by  none  other. — 
Stethoscope. 

The  character  and  merits  of  Dr.  Ramsbotham's 
work  are  so  well  known  and  thoroughly  established, 
that  comment  is  unnecessary  and  praise  superfluous 
The  illustrations,  which  are  numerous  and  accurate 


are  executed  in  the  highest  style  of  art.     We  cannot  i  this  work  will  afford  him. — Am.  Jour,  of  the  Med. 
too  highly  recommend  the  work  to  our  readers. — St.  |  Sciences. 
Louis  Med.  and  Surg.  Journal.  I 


nnURGHILL  [FLEETWOOD),  M.D.,  M.R.I. A. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.     A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  additior  s 
by  D.  Francis  Condie,  M.  D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Chil- 
dren,'' &c.  With  one  hundred  and  ninety- four  illustrations.  In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.     Extra  cloth,  $4  00  ;  leather,  $5  00. 


These  additions  render  the  work  still  more  com- 
plete and  acceptable  than  ever;  and  we  can  com- 
mend it  to  the  profession  with  great  cordiality  and 
pleasure. — Cin  Hnnati  Lancet. 

Few  wtirk?  on  this  branch  of  medical  science  are 
equal  to  it,  certainly  none  excel  it,  whether  in  regard 
to  theory  or  practice — Brit.  Am.  Journal. 

Ko  treatise  on  obstetrics  with  which  we  are  ac- 


quainted can  compate  favorably  with  this,  in  re- 
spect to  the  amount  ofraaterial  which  has  beer  gath- 
ered from  every  source. — Boston  Med.  and  Stirg. 
Journal . 

There  is  no  better  text-book  for  students,  or  work 
of  reference  and  study  for  the  practising  physician 
than  this.  It  should  adorn  and  enrich  every  medical 
library. — Chicago  Med.  Journal. 


MONTGOMERY'S    EXPOSITION    OF    THE    SIGNS  i 
AND  SYMPTOMS    OF    PREGNANCY.     With  two  | 
exquisite  colored  plates,  and  numerous  wood  cats. 
In  i  vol.  8vo.,  of  nearly  600  pp.,  extra  cloth.    $3  75. 

SlaBY'S   SYSTEM  OF  MIDWIFERY.     With  Notes 
and   Additional   Illustrations.     Second   American  I 


edition.  One  volume  octavo,  extra  cloth,  422  pages 
^12  50. 
DEWEES'S  COMPREHENSIVE  SYSTEM  OF  MID- 
WIFERY. Twelfth  edition,  with  the  author's  latt 
improvements  and  corrections.  In  one  octavo  vol- 
ume, extra  cloth.,  of  600  pages.    $3  60. 


Henry  C.  Lea's  Publications — (Surgery). 


flROSS  {SAMUEL  D.),  M.D., 

'-^  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

A  SYSTEM  OF  SURGERY:    Pathological,  Diagnostic,  Therapeutic, 

and  Operative.     Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.     Fifth  edition, 
carefully  revised,  and  improved.    In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2300  pages,  strongly  bound  in  leather,  with  raised  bands,  $15.    {Just  Ready .) 
The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.    In  the 
present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully  up  to 
the  day.     To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  enlarged  by 
nearly  one-fourth,  notwithstanding  which  the   price  has  been  kept  at  its  former  very  moderate 
rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  ol  matter  is 
condensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary  octavos. 
This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  binding,  renders 
it  one  of  the  cheapest  works  accessible  to  the  profession.     Every  subject  properly  belonging  to  the 
domain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this  work  may  be  said  to 
have  in  it  a  surgical  library. 


It  mu.st  long  remain  the  most  comprehensive  work 
on  thisimpurtam  part  of  medicine. — Boston  Medical 
and  Surgical  Journal,  March  '23,  186.5. 

We  have  compared  it  with  most  of  our  standard 
works,  ouch  as  those  of  Erichsen,  Miller,  Fergusson, 
Syme,  and  others,  and  we  must,  in  justice  to  our 
author,  award  it  the  pre-eminence.  As  a  work,  com- 
plete in  almost  every  detail,  no  matter  how  minute 
or  trifling,  and  embracing  every  subject  known  in 
the  principles  and  practice  of  surgery,  we  believe  it 
stands  without  a  rival.  Dr.  Gross,  in  his  preiace,  re- 
marks "my  aim  has  been  to  embrace  the  whole  do- 
main of  surgery,  and  to  allot  to  every  subject  its 
legitimate  claim  to  notice;"  and,  we  assure  our 
readers,  he  has  kept  his  word.  It  is  a  work  which 
we  can  most  confldently  recommend  to  our  brethren, 
for  its  utility  is  becoming  the  more  evident  the  longer 
it  is  upon  tie  shelves  of  our  library.— Cawada  Med. 
Journal,  September,  186.5. 

The  first  two  editions  of  Professor  Gross'  System  of 
Surgery  are  so  well  known  to  the  profession,  and  so 
highly  prized,  that  it  would  be  idle  for  us  to  speak  in 
praise  of  this  voik.— Chicago  Medical  Journal, 
September,  186.5. 

We  gladly  indorse  the  favorable  recommendation 
of  the  work,  both  as  regards  matter  and  style,  which 
we  made  when  noticing  its  tirsl  appearance.— .Briii*/* 
and  Foreign  Medico-Chirurgical  Review,  Oct.  1865. 

The  most  complete  work  that  has  yet  issued  from 
the  press  on  the  science  and  practice  of  surgery. — 
London  Lancet. 

This  system  of  surgery  is,  we  predict,  destined  to 
take  a  commanding  position  in  our  surgical  litera- 
ture, and  be  the  crowning  glory  of  the  author's  well 
earned  fame.  As  an  authority  on  general  surgical 
subjects,  this  work  is  long  to  occupy  a  pre-eminent 
place,  not  only  at  home,  but  abroad.     We  have  no 


hesitation  in  pronouncing  it  without  a  rival  in  our 
language,  and  equal  to  the  best  systems  of  surgery  in 
Any  language. — N.  Y.  Med.  Journal. 

Wot  only  by  far  the  best  text-book  on  the  subject, 
as  a  whole,  within  the  reach  of  American  students, 
but  one  which  will  be  much  more  than  ever  likely 
to  be  resorted  to  and  regarded  as  a  high  authority 
abroad. — Am.  Journal  Med.  Sciences,  Jan.  1865. 

The  work  contains  everything,  minor  and  major, 
operative  and  diagnostic,  including  mensuration  and 
examination,  venereal  diseases,  and  uterine  manipu- 
lations and  operations.  It  is  a  complete  Thesaurus 
of  modern  surgery,  where  the  student  and  practi- 
tioner shall  not  seek  in  vain  for  what  they  desire. — 
San  Francisco  Med.  Press,  Jan.  1865. 

Open  it  where  we  may,  we  find  sound  practical  in- 
formation conveyed  in  plain  language.  This  book  is 
no  mere  provincial  or  even  national  system  of  sur- 
gery, but  a  work  which,  while  very  largely  indebted 
to  the  past,  has  a  strong  claim  on  the  gratitude  of  the 
future  of  surgical  science. — Edinburgh  Med.  Journal, 
Jan.  1865. 

A  glance  at  the  work  is  sufficient  to  show  that  the 
author  and  publisher  have  spared  no  labor  in  making 
it  the  most  complete  "System  of  Surgery"  ever  pub- 
lished in  any  country. — St.  Louis  Med.  and  Surg. 
Journal,  April,  1865. 

A  system  of  surgery  which  we  think  unrivalled  in 
our  language,  and  which  will  indelibly  associate  his 
name  with  .surgical  science.  And  what,  in  our  opin- 
ion, enhances  the  value  of  the  work  is  that,  while  the 
practising  surgeon  will  find  all  that  he  requires  in  it, 
it  is  at  the  same  time  one  of  the  most  valuable  trea- 
tises which  can  be  put  into  the  hands  of  the  student 
seeking  to  know  the  principles  and  practice  of  this 
branch  of  the  profession  which  he  designs  subse- 
quently to  follow. — The  Brit.  Am.Jowrn.,  Montreal. 


UT  THE  SAME  AUTHOR. 

A   PRACTICAL    TREATISE    ON    FOREIGN    BODIES   IN   THE 

AIR-PASSAGES.     In  1  vol.  8vo.  cloth,  with  illustrations,    pp.  468.     $2  75. 


8  ;eY'S    OPERATIVE  SURGERY.     In  1   vol.    8vo. 

jloth,  of  over  650  pages  ;  with  about  100  wood-cuts. 

*3  2.5. 
COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 

Pkactice  of  SuRiiER y.  In  1  vol.  8 vo.  cloth,  750  p.  $2. 


GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SUR- 
]      QERY.   Eighth  edition,  improved  and  altered.  With 
thirty-four  plates.     In  two  handsome  octavo  vel- 
1      umes,  about  1000  pp. ,  leather,  raised  bands.  $6  60. 


M 


ILLER  {JAMES), 

Late  Professor  of  Surgery  in  the  University  of  Edinburgh,  &e. 

PRINCIPLES  OF  SURGERY.     Fourth  American,  from  the  third  and 

revised  Edinburgh  edition.     In  one  large  and  very  beautiful  volume  of  700  pages,  with 
two  hundred  and  forty  illustrations  on  wood,  extra  cloth.     $3  76. 


B 


T  THE  SAME  AUTHOR.  

THE   PRACTICE    OF    SURGERY.     Fourth  American,  from  the  last 

Edinburgh  edition.  Revised  by  the  American  editor.  Illustrated  by  three  hundred  and 
sixty-four  engravings  on  wood.  In  one  large  octavo  volume  of  nearly  700  pages,  extra 
cloth.     $3  75.  

SARGENT  {F.  W.),  M.D. 
O^   BA^DAUI^G  AND    OTHER   OPERATIONS   OF   MINOR 

SURGERY.  Newedition,  with  an  additional  chapter  on  Military  Surgery.  One  handsome 
royai  l2mo.  volume,  of  nearly  400  pages,  with  184  wood-cuts.     Extra  cloth,  $1  75. 


Henry  C.  Lea's  Publications — (Surgery). 


27 


ASHHURST  {JOHN,  Jr.).  M.D., 

Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

THE    PRINCIPLES   AND    PRACTICE   OF    SURGERY.     In  one 

very  large  and  handsome  octavo  volume  of  about  1000  pages,  with  nearly  550  illustrations, 
extra  cloth,  $6  50;  leather,  raised  bands,  $7  50.      {Just  Iss^ted.) 

The  object  of  the  author  has  been  to  present,  within  as  condensed  a  compass  as  possible,  a 
complete  treatise  on  Surgery  in  all  its  branches,  suitable  both  as  a  text-book  for  the  student  and 
a  work  of  reference  for  the  practitioner.  So  much  has  of  late  years  been  done  for  the  advance- 
ment of  Surgical  Art  and  Science,  that  there  seemed  to  be  a  want  of  a  work  which  should  present 
the  latest  aspects  of  every  subject,  and  which,  by  its  American  character,  should  render  accessible 
to  the  profession  at  large  the  experience  of  the  practitioners  of  both  hemispheres.  This  has  been 
the  aimof  the  author,  and  it  is  hoped  that  the  volume  will  be  found  to  fulfil  its  purpose  satisfac- 
torily.    The  plan  and  general  outline  of  the  work  will  be  seen  by  the  annexed 

CONDENSED  SUMMARY  OF  CONTENTS. 

Chapter  I.  Inflammation.  II.  Treatment  of  Inflammation.  III.  Operations  in  general: 
Anaesthetics.  IV.  Minor  Surgery.  V.  Amputations.  VI.  Special  Amputations.  VII.  Eflfects 
of  Injuries  in  General  :  Wounds.  VIII.  Gunshot  Wounds.  IX.  Injuries  of  Bloodvessels.  X. 
Injuries  of  Nerves,  Muscles  and  Tendons,  Lymphatics,  Bursae,  Bones,  and  Joints.  XI.  Fractures. 
XII.  Special  Fractures.  XIII.  Dislocations.  XIV.  Effects  of  Heat  and  Cold.  XV.  Injuries 
of  the  Head.  XVI.  Injuries  of  the  Back.  XVII.  Injuries  of  the  Face  and  Neck.  XVIII. 
Injuries  of  the  Chest.  XIX.  Injuries  of  the  Abdomen  and  Pelvis.  XX.  Diseases  resulting  from 
Inflammation.  XXI.  Erysipelas.  XXII.  Pyaemia  XXIII.  Diathetic  Diseases  :  Struma  (in- 
cluding Tubercle  and  Scrofula);  Rickets.  XXIV.  Venereal  Diseases;  Gonorrhoea  and  Chancroid. 
XXV.  Venereal  Diseases  continued  :  Syphilis.  XXVI.  Tumors.  XXV 11.  Surgical  Diseases  of 
Skin,  Areolar  Tissue,  Lymphatics,  Muscles,  Tendons,  and  Bursae.  XXVIII.  Surgical  Disease 
of  Nervous  System  (including  Tetanus).  XXIX.  Surgical  Diseases  of  Vascular  System  (includ- 
ing Aneurism).  XXX.  Diseases  of  Bone.  XXXI.  Diseases  of  Joints.  XXXII.  Excisions. 
XXXIII.  Orthopaedic  Surgery.  XXXIV.  Diseases  of  Head  and  Spine.  XXXV.  Dise.Tses  of  the 
Eye.  XXXVI.  Diseases  of  the  Ear.  XXXVII.  Diseases  of  the  Face  and  Neck.  XXXVIII. 
Diseases  of  the  Mouth,  Jaws,  and  Throat.  XXXIX.  Diseases  of  the  Breast.  XL.  Hernia.  XLI. 
Special  Hernise.  XLII.  Diseases  of  Intestinal  Canal.  XLIII.  Diseases  of  Abdominal  Organs, 
and  various  operations  on  the  Abdomen.  XLIV.  Urinary  Calculus  XLV.  Diseases  of  Bladder 
and  Prostate.      XLVI.  Diseases  of  Urethra.      XLVII.  Diseases  of  Generative  Organs.     Index. 


Its  author  has  evidently  tested  the  writings  and 
experiences  of  the  past  and  present  in  the  crucible 
of  a  careful,  analylic,  and  honoiable  mind,  and  faith- 
fully endeavored  to  bring  his  work  up  to  the  level  of 
the  highest  standard  of  practical  surgery  He  is 
frank  and  detiuite,  and  gives  us  opinions,  and  gene- 
rally sound  ones,  instead  of  a  mere  resurne  of  the 
opinions  of  others.  He  is  conservative,  but  not  hide- 
bound by  authority.  His  style  is  clear,  elegant,  and 
scholarly.  The  wi  rk  is  anadmirable  text  book,  and 
a  useful  book  of  reference  It  is  a  credit  to  American 
professional  literature,  and  one  of  the  first  ripe  fruits 
of  the  soil  fertilized  by  the  blood  of  oar  late  unhappy 
war.— aV.  Y.  Med.  Record,  Feb.  1,  1S72. 


Indeed,  the  work  as  a  whole  must  be  regarded  as 
an  excellent  and  concise  exponent  of  modern  sur- 
gery, and  as  such  it  will  be  found  a  valuable  text- 
book for  the  student,  and  a  useful  book  of  reference 
for  the  general  practitioner. — N.  Y.  Med.  Journal, 
Feb.  1S7-^ 

It  gives  us  great  pleasure  to  call  the  attention  of  the 
profession  to  this  excellent  work.  Our  knowledge  of 
its  talented  and  accomplished  author  led  us  to  expect 
from  him  a  very  valuable  treatise  upon  subjects  to 
which  he  has  repeatedly  given  evidence  of  having  pro- 
fitably devoted  much  time  and  labor,  and  we  are  in  no 
way  disappointed.— PAt/a.  Mtd.  Times,  Feb.  1,  1S72. 


P 


IRRIE  (  WILLIAM),  F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Aberdeen. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.     Edited  by 

John  Neill,  M.  D.,  Professor  of  Surgery  in  the  Penna.  Medical  College,  Surgeon  to  the 
Pennsylvania  Hospital,  &c.  In  one  very  handsome  octavo  volume  of  780  pages,  with  316 
illustrations,  extra  cloth.     $3  75. 


H 


AMIL TON  ( FRA NK  H. ),  M.D., 

Professor  of  Fracture.),-  and  Di.ilncations,  ice,  in  Bellevue  Hosp.  Med.  College,  New  York. 

PRACTICAL  TREATISE    ON   FRACTURES  AND   DISLOCA- 

TIONS.  Fourth  edition,  thoroughly  revised.  In  one  large  and  handsome  octavo  volume 
of  nearly  800  pages,  with  several  hundred  illustrations.  Extra  cloth,  $5  75  ;  leather,  $6  75. 
{Just  Issued. ) 

rable  treatise,  which  we  have  always  considered  the 
most  complete  and  reliable  work  on  the  subject.  As 
a  whole,  the  work  is  without  an  equal  in  the  litera- 
ture of  the  profession. — Boston  Med.  and  Surg. 
Journ.,  Oct.  12,  IS?]. 

It  is  unnecessary  at  this  time  to  commend  the  book, 
except  to  such  as  are  beginners  in  the  study  of  this 
particular  branch  of  surgery.  Every  practical  sur- 
geon in  this  country  and  abroad  knows  of  it  as  a  most 
trustworthy  guide,  and  one  which  they,  in  common 
with  us,  would  unqualifiedly  recommend  as  the  high- 
est authority  in  any  language. — N  Y.  Med.  Record, 
Oct.  16,  1S71 


It  is  not,  of  course,  our  intention  to  review  in  ex- 
tenso,  Hamilton  on  "Fractures  and  Dislocations." 
Eleven  years  ago  such  review  might  not  have  been 
out  of  place  ;  to-day  the  work  is  an  authority,  so  well, 
so  generally,  and  so  favorably  known,  that  it  cmly 
remains  for  the  reviewer  to  say  that  a  new  edition  is 
just  out,  and  it  is  better  than  either  of  its  predeces- 
sors.— Cincinnati  Clinic,  Oct.  14,  1S71. 

Undoubtedly  the  best  woi-k  on  Fractures  and  Dis- 
locations in  the  English  language. — Cincinnati  Med. 
kfpertory,  Oct.  1871. 


We  have  once  more  before  us  Dr  Hamilton's  admi- 


28  Henry  C.  Lea's  Publications — {Surgery). 

PRICES  EN  [JOHN  E.), 

-*-•  Professor  of  Surgery  in  University  College,  London,  etc. 

THE  SCIENCE  AND  ART  OF  SURaERY;  being  a  Treatise  on  Sur- 

gical  Injuries,  Diseases,  and  Operations.  Revised  by  the  author  from  the  Sixth  and 
enlarged  English  Edition.  Illustrated  by  over  seven  hundred  engravings  on  wood.  In 
two  large  and  beautiful  octavo  volumes  of  over  1700  pages,  extra  cloth,  $9  00  ;  leather, 
$11  00.      {Just  Ready.) 

Author'' s  Preface  to  the  New  American  Edition. 

"  The  favorable  reception  with  which  the  '  Science  and  Art  of  Surgery'  has  been  honored  by  the 
Surgical  Profession  in  the  United  States  of  America  has  been  not  only  a  source  of  deep  gratifica- 
tion and  of  just  pride  to  me,  but  has  laid  the  foundation  of  many  professional  friendships  that 
are  amongst  the  ngreeable  and  valued  recollections  of  my  life.  ■' 

"I  have  endeavored  to  make  the  present  edition  of  this  work  more  deserving  than  its  predecessors 
of  the  favor  that  has  been  accorded  to  them.     In  consequence  of  delays  that  have  unavoidably 
occurred  in  the  publication  of  the  Sixth  British  Edition,  time  has  been  afforded  to  me  to  add  to  this 
one  several  paragraphs  which  I  trust  will  be  found  to  increase  the  practical  value  of  the  work." 
London,  Oct.  1S72. 

On  no  former  edition  of  this  work  has  the  author  bestowed  more  pains  to  render  it  a  complete  and 
satisfactory  exposition  of  British  Surgery  in  its  modern  aspects.  Every  portion  has  been  sedu- 
lously revised,  and  a  large  number  of  new  illustrations  have  been  introduced.  In  addition  to  the 
materinl  thus  added  to  the  English  edition,  the  author  has  furnished  for  the  American  edition  such 
material  as  has  accumulated  since  the  passage  of  the  sheets  through  the  press  in  London,  so  that 
the  work  as  now  presented,to  the  American  profession,  contains  his  latest  views  and  experience. 

The  increase  in  the  size  of  the  work  has  seemed  to  render  necessary  its  division  into  two  vol- 
umes. Great  care  has  been  exercised  in  its  typographical  execution,  and  it  is  confidently  pre- 
sented as  in  every  respect  worthy  to  maintain  the  high  reputation  which  has  rendered  it  a  stand- 
ard authority  on  this  department  of  medical  science. 

These  are  only  a  few  of  the  points  in  which  the  ;  states  in  his  preface,  they  are  not  confined  to  any  one 
present  edition  of  Mr.  Eriohsen's  work  surpasses  its  portion,  but  are  distributed  generally  through  the 
predecessors.  Throughout  there  is  evidence  of  a  j  subjects  of  which  the  work  treats.  Certainly  cue  of 
laborious  care  and  solicitude  in  seizing  the  passing!  the  most  valuable  sections  of  the  book  seems  to  us  to 
knowledge  of  the  day,  which  reflect;,  tlie  greatest  be  that  which  treats  of  the  diseases  of  the  arteries 
credit  on  the  author,  and  much  enhances  the  value  J  and  the  operative  proceedings  which  they  necessitate, 
of  hiswork.  Wecanonly  admire  the  industry  which  '■  In  few  text-books  is  so  much  carefully  arranged  in- 
has  enabled  Mr.  Erichsen  thus  to  succeed,  amid  the  ,  formation  collected. — London  Med.  Times  and  Gaz., 
di.stractionsof  active  practice,  in  producing  emphatic-  \  Oct.  26,  1872. 

ally  THE  book  of  reference  and  study  for  Britisli  prac- ;      Ti,e  entire  work,  complete,  as   the  great  Engli;<h 
titioners  o£  Bavgevy.—Londo7i  Lancet,  Oct.  26,  1872.     i  treatise  on  Surgery  of  our  own  time,  is,  we  can  assure 

Considerable  clianges  have  been  made  in  this  edi-  ,  our  readers,  equally  well  adapted  for  themost  juuior 
tion,  aud  nearly  a  hundred  new  illustrations  have  i  student,  and,  as  a  book  of  reference,  for  the  advanced 
been  added.    It  is  difficult  in  a  small  compass  to  point     practitioner, — Dublin  Quarterly  Journal. 
out  the  alterations  and  additions  ;  for,  as  the  author 


D 


RUITT  [ROBERT],  M.R.C.S.,  Src. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition  Illus- 
trated with  four  hundred  and  thirty -two  wood  engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages.    Extra  cloth,  $4  00 ;  leather,  $5  00. 

practice  of  surgery  are  treated,  and  so  clearly  and 
perspicuously,  as  to  elucidate  every  important  topic. 
We  have  examined  the  book  most  thoroughly,  and 
can  ^ay  that  this  success  is  well  merited.  His  book, 
moreover,  possesses  the  inestimable  advantages  of 
having  the  subjects  perfectly  well  arranged  and  clas- 
sified, and  of  being  written  in  a  style  at  once  clear 
^nd  succinct. — Am.  Journal  of  Med.  Sciences. 


All  that  the  surgical  student  or  practitioner  could 
desire. — Dublin  Quarterly  Journal. 

It  is  a  most  admirable  book.  We  do  not  know 
when  we  have  examined  one  with  more  pleasure. — 
Boston  Med.  and  Surg.  Journal. 

In  Mr.  Druitt's  book,  though  containing  only  some 
seven  hundred  pages,  both   the  principles  and  the 


A 


SET  ON  [T.  J.). 
ON  THE   DISEASES,  INJURIES,  AND  MALFORMATIONS   OF 

THE  RECTUM  AND  ANUS;  with  remarks  on  Habitual  Constipation.  Second  American, 
from  the  fourth  and  enlarged  London  edition.  With  handsome  illustrations.  In  one  very 
beautifully  printed  octavo  volume  of  about  300  pages.     $'6  25. 


T>1GEL0  W  [HENRY  J.).  M.  D., 

-*-'  Professor  of  Surgery  in  the  Massac.httsetts  Med.  College. 

ON   THE   MECHANISM   OF    DISLOCATION  AND  FRACTURE 

OF  THE  HIP.  With  the  Reduction  of  the  Dislocation  by  the  Flexion  Method.  With 
numerous  original  illustrations.  In  one  very  handsome  octavo  volume.  Cloth.  $2  60. 
{Lately  Issiied.) 

TAWSON  [GEORGE),  F.  R.  C.  S.,  Engl., 

■*-'  Assistant  Surgeon  to  the  Royal  London  Ophthalmic  Hospital,  Mnorfields,  See. 

INJURIES  OF  THE  EYE,  ORBIT,  AND  EYELIDS:  their  Imme- 

diate   and  Remote  Effects.      With  about  one  hundred  illustrations.      In  one  very  hand- 
some octavo  volume,  extra  cloth,  $.3  50. 

It  is  an  admirable  practical  book  in  the  highest  and  best  sense  of  the  phrase. — London  Medical  Timet 
and  Gazette,  May  18,  1867. 


Henry  C.  Lea's  Publications — (Surgery). 


29 


-jDRYANT  {THOMAS),  F.R.C.S., 

■*-'  Surgeon  to  Guy's  Hospital. 

THE   PRACTICE    OF    SURGEPY.     With  over  Five  Hundred  En- 

gravings  on  Wood.     In  one  large  and  very  handsome  octavo  volume  of  nearly  1000  pages, 
extra  cloth,  $6  25;  leather,  raised  bands,  %1  26.      (Just  Issued.) 


Again,  the  author  gives  us  his  own  practice,  his 
own  beliefs,  and  illustrates  by  liis  own  cases,  or  those 
treated  in  Guy's  Hospital.  This  feature  adds  joint 
emphasis,  and  a  solidity  to  his  statements  that  inspire 
confidence.  One  feels  himself  almost  by  the  side  of 
the  surgeon,  seeing  his  work  and  hearing  his  living 
words.  The  views,  etc  ,  of  other  surgeons  are  con- 
sidered calmly  and  fairly,  but  Mr.  Bryant's  are 
adopted.  Thus  the  work  is  not  a  compilation  of 
other  writings;  it  is  not  an  encyclopajdia,  but  the 
plain  statements,  on  practical  points,  of  a  man  who 
has  lived  and  breathed  and  had  his  being  in  the 
richest  surgical  experience.  The  whole  profession 
owe  a  debt  of  gratitude  to  Mr  Bryant,  for  his  work 
in  their  behalf.  We  are  confident  that  the  American 
profession  will  give  substantial  testimonial  of  their 
feelings  towards  both  author  and  publisher,  by 
speedily  exhausting  this  edition.  We  cordially  and 
heartily  commend  it  to  our  friends,  and  think  that 
Di)  live  surgeon  can  afford  to  be  without  it  — Detroit 
Review  of  Med.  and  Pharmacy,  August,  1S73. . 

As  a  manual  of  the  practice  of  surgery  for  the  use 
of  the  student,  we  do  not  hesitate  to  pronounce  Mr. 
Bryant's  book  a  filrst-rate  work.  Mr.  Bryant  has  a 
good  deal  of  the  dogmatic  energy  which  goes  with 
the  clear,  pronounced  opinions  of  a  man  whose  re- 
flections and  experience  have  moulded  a  character 
not  wanting  in  firmness  aud  decision.  At  the  same 
time  he  teaches  with  the  enthusiasm  of  one  who  has 
faith  in  his  teaching;  he  speaks  as  one  having  au- 
thority, and  herein  lies  the  charm  and  excellence  of 
his  work.     He  states   the  opinions  of  others  freely 


and  fairly,  yet  it  is  no  mere  compilation.  The  book 
combines  much  of  the  merit  of  the  manual  with  the 
merit  of  the  monograph.  One  may  recognize  iu 
almost  every  chapter  of  the  ninety-four  of  which  the 
work  is  made  up  the  acuteness  of  a  surgeon  who  has 
seen  much,  and  observed  closely,  and  who  gives  forth 
the  results  of  actual  experience.  In  conclusion  we 
repeat  what  we  stated  at  fir.^t,  that  Mr.  Bryant's  book 
is  one  which  we  can  conscientiously  recommend  bi)th 
to  praclitiuuers  and  students  as  an  admirable  work. 
— Dublin  Joiirn.  of  Med.  Science,  August,  1S73. 

Mr.  Bryant  has  long  been  known  to  the  reading 
portion  of  the  profession  as  an  able,  clear,  and  graphic 
writer  upon  surgical  subjects.  The  volume  before 
us  is  one  eminently  upon  the  practice  of  surgery  and 
not  one  which  treats  at  length  on  surgical  pathology, 
though  the  views  that  are  entertained  upon  this  sub- 
ject are  sufficiently  interspersed  through  the  work 
for  all  practical  purposes.  As  a  text-book  we  cheer- 
fully I'ecommeud  it,  feeling  convinced  that,  from  the 
subject-matter,  and  the  concise  and  true  way  Mr. 
Bryant  deals  with  his  subject,  it  will  prove  a  for- 
midable riral  among  the  numerous  surgical  text- 
books which  are  offered  to  the  student. — N.  Y.  Med. 
Record,  June,  1S73. 

This  i.«,  as  the  preface  states,  an  entirely  new  book, 
and  contains  in  a  moderately  condensed  form  all  the 
surgical  information  necessary  to  a  general  practi- 
tioner. It  is  written  in  a  spirit  couRistent  with  the 
present  improved  standard  of  medical  and  surgical 
science. — American  Journal  of  Obstetrics,  August, 
1S73. 


A 


{^ELLS  {J.  SOELBERG), 

Professor  of  Ophthalmology  in  King^s  College  Hospital,  &e. 

TREATISE  ON  DISEASES  OF  THE  EYE.      Second  Americar, 

from  the  Third  and  Revised  London  Edition,  with  additions;  illustrated  with  numerous 
engravings  on  wood,  and  six  colored  plates.     Together  with  selections  from  the  Test-types 
of  Jaeger  and  Snellen.     In  one  large  and  very  handsome  octavo  volume  of  nearly  800 
pages  ;  cloth,  So  00  ;  leather,  S6   00.      (Notv  Ready.) 
The  continued  demand  for  this  work,  both  in  England  and  this  country,  is  sufficient  evidence 
that  the  author  has  succeeded  in  his  effort  to  supply  within  a  reasonable  compass  n  full  practical 
digest  of  ophthalmology  in  its  most  modern  aspects,  while  the  call  for  repeated  editions  has  en- 
aiiled  him  in  his  revisions  to  maintain  its  position  abreast  of  the  most  recent   investigations  and 
improvements.     In  again  reprinting  it,  every  effort  has  been   made  to  adapt  it  thoroughly  to  the 
wants  of  the  American   practitioner.      Such  additions  as  seemed  desirable  have  been   introduced 
by  the  editor,  Dr.  I.  Minis  Hays,  and  the  number  of  illustrations  has  been  largely  increased.     The 
importance  of  test-types  as  an  aid  to  diagnosis  is  so  universally  acknowledged  at  the  present  d;iy 
that  it  seemed  essential  to  the  completeness  of  the  work  that  they  should  be  added,  and  as  the 
author  recommends  the  use  of  those  both  of  Jaeger  and  of  Snellen  for  diiferent  purposes,  selec- 
tions have  been  made  from  each,  so  that  the  practitioner  may  have  at  command  all  the  assist- 
ance necessary.     Although  enlarged  by  one  hundred   pages,  it  has  been  retained  at  the  former 
very  moderate  price,  rendering  it  one  of  the  cheapest  volumes  before  the  profession. 
A  few  notices  of  the  previous  edition  are  subjoined. 


In  this  respect  the  work  before  us  is  of  much  more 
service  to  the  general  practitioner  than  those  heavy 
compilations  which,  in  giving  every  person's  views, 
too  often  neglect  to  specify  those  which  are  most  in 
accordance  with  the  author's  opinions,  or  in  general 
acceptance.  We  have  no  hesitation  iu  recommending 
this  treatise,  as,  on  the  whole,  of  all  English  works 
on  the  subject,  the  one  best  adapted  to  the  wants  of 
the  general  ^viL.ciiiio'a.ei.  — Edinburgh  Med.  Journal, 
March,  1870. 

A  treatise  of  rare  merit.     It  is  practical,  compre-  {  the  eye 
hensive,  and  yet  concise.  Upon  those  subjects  usually  | 


found  difficult  to  the  student,  he  has  dwelt  at  length 
and  entered  into  full  explanation.  After  a  careful 
perusal  of  its  contents,  we  can  unhesitatingly  com- 
mend it  to  all  wlio  desire  to  consult  a  really  good 
work  on  ophhtalmic  science. — Leavenworth  Mde.  Her- 
ald, Jan.  1S70. 

Without  doubt,  one  of  the  best  works  upon  the  sub 

ject  which  has  ever  been  published  ;  it  is  complete  on 

the  subject  of  which  it  treats,  and  is  a  necessary  work 

for  every  physician  who  attempts  to  treat  diseases  of 

Dominion  Med.  Journal,  Sept.  1869. 


fA  URENCE  {JOHN  Z.),  F.  R.  C.  S., 

Editor  of  the  Ophthalmic  Review,  &c. 

A  HANDY-BOOK  OF   OPHTHALMIC    SURGERY,  for  the  use  of 

Practitioners.  Second  Edition,  revised  and  enlarged.  With  numerous  illustrations.  In 
one  very  handsome  octavo  volume,  extra  cloth,  %'6  00.  [Lately  Iss7ied.) 
For  those,  however,  who  must  assume  the  care  of  [  edition  those  novelties  which  have  secured  the  confi- 
diseases  and  injuries  of  the  eye,  and  who  are  too  dence  of  the  profession  since  the  appearance  of  his 
much  pressed  for  time  to  study  the  classic  works  on  last.  The  volume  has  been  considerably  enlarged 
the  subject,  or  those  recently  published  by  Stellwag,  and  improved  by  the  revision  and  additions  of^its 
Wells,  Bader,  and  others,  Mr.  Laurence  will  prove  a  author,  expresslv  for  the  American  edition. — Am. 
safe  and  trustworthy  guide.    He  ha*  described  in  this  1  Journ.  Med.  Sciences,  Jan.  1870. 


30  Henry  C.  Lea's  Publications — {Surgery,  &c.). 

rPHOMPSON  [SIR  HENR F), 

■*-  Surgeon  and  Profennor  of  Olinical  Surgery  to  University  College  Hospital . 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.    With 

illustrations  on  wood.     In  one  neat  octavo  volume,  extra  cloth.     $2  25. 

These  lectures  stand  the  severe  test.  They  are  in-  I  tical  hints  so  useful  for  the  siudent,  and  even  more 
Btructive  without  being  tedious,  and  simple  without  yaluahle  to  the  young  practitioner. — Edinburgh  Med. 
being  dififuse;  and  they  include  many  of  those  prac-  |  Journal,  April,  1S69. 


B 


Y  TEE  SAME  AUTHOR. 


ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OP 

THE  URETHUA  AND  URINARY  FISTULiE.     With  plates  and  wood-cuts.     From  the 
third  and  revised  English  edition.    In  one  very  handsome  octavo  volume,  extra  cloth,  $3  60. 
{Lately  Puhlished.) 
This  classical  work  has  so  long  been  recognized  as  a  standard  authority  on  its  perplexing  sub- 
jects that  it  should  be  rendered  accessible  to  the  American  profession.      Having  enjoyed  the 
advantage  of  a  revision  at  the  hands  of  the  author  within  a  few  months,  it  will  be  found  to  present 
his  latest  views  and  to  be  on  a  level  with  the  most  recent  advances  of  surgical  science. 

With  a  work  accepted  as  the  authority  upon  the  I  ably  known  by  the  profession  as  this  before  us,  must 
subjects  of  which  it  treats,  an  extended  notice  would  |  create  a  demand  for  it  from  those  who  would  keep 
be  a  work  of  supererogation.  The  simple  announce-  I  themselves  well  up  in  this  department  of  surgery. — 
ment  of  another  edition  of  a  work  so  well  and  favor-  |  St.  Louis  Med.  Archives,  Feb.  1870. 


-DY  THE  SAME  AUTHOR.     (Just  Ready.) 

THE  DISEASES    OF    THE   PROSTATE,  THEIR   PATHOLOGY 

AND  TREATMENT.     Fourth  Edition,  Revised.     In  one  very  handsome  octavo  volume  of 

'i^bb  pages,  with  thirteen  piates,  plain  and  colored,  and  illustrations  on  wood.     Cloth,  $3  75. 

This  work  is  recognized  in  England  as  the  leading  authority  on  its  subject,  and  in  presenting 

it  to  the  American   profession,  it  is  hoped  that  it  will  be  found   a  trustworthy  and  satisfactory 

guide  in  the  treatment  of  an  obscure  and  important  class  of  affections. 


^ALES  [PHILIP  S.),  M.  D.,  Surgeon  U.  S.  N. 


MECHANICAL  THERAPEUTICS:  a  Practical  Treatise  on  Surgical 

Apparatus,  Appliances,  and  Elementary  Operations  :  embracing  Minor  Surgery,  Band- 
aging, Orthopraxy,  and  the  Treatment  of  Fractures  and  Dislocations.  With  six  hundred 
and  forty -two  illustrations  on  wood.  In  one  large  and  handsome  octavo  volume  of  about 
700  pages:  extra  cloth,  $5  75;  leather,  $6  75. 


/TAFLOR  [ALFRED  S.),  M.D., 

■*■  Lecturer  on  Med.  Jurisp.  and  Qhemistry  in  Guy's  Hospital. 

MEDICAL  JURISPRUDENCE.     Seventh  American  Edition.     Edited 

by  John  J.  Reese,  M.D.,  Prof,  of  Med.  Jurisp.  in  the  Univ.  of  Penn.  In  one  large 
octavo  volume.     Cloth,  $5  00;   leather,  $6  00.      {Now  Ready.) 

In  preparing  for  the  press  this  seventh  American  edition  of  the  "  Manual  of  Medical  Jurispru- 
dence" the  editor  has,  through  the  courtesy  of  Dr.  Taylor,  enjoyed  the  very  great  advantage  of 
consulting  the  sheets  of  the  new  edition  of  the  author's  larger  work,  "  The  Principles  and  Prac- 
tice of  Medical  Jurisprudence,"  which  is  now  ready  for  publication  in  London.  This  has  enabled 
him  to  introduce  the  author's  latest  views  upon  the  topics  discussed,  which  are  believed  to  bring 
the  work  fully  up  to  the  present  time. 

The  notes  of  the  former  editor,  Dr.  Hartshorne,  as  also  the  numerous  valuable  references  to 
American  practice  and  decisions  by  his  successor,  Mr.  Penrose,  have  been  retained,  with  but  few 
slight  exceptions;  they  will  be  found  inclosed  in  brackets,  distinguished  by  the  letters  (II.)  and 
(P.).  The  additions  made  by  the  present  editor,  from  the  material  at  his  couiniand,  amount  to 
about  one  hundred  pages;   and  his  own  notes  are  designated  by  the  letter  (K.). 

Several  subjects,  not  treated  of  in  the  former  edition,  have  been  noticed  in  the  present  one, 
and  the  work,  it  is  hoped,  will  be  found  to  merit  a  continuance  of  the  confidence  which  it  has  so 
long  enjoyed  as  a  standard  authority. 


or  THE  SAME  AUTHOR.     {Now  Ready.) 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 

DENCE.     Second    Edition,   Revised,  with    numerous   Illustrations.     In    two    very  large 

octavo  volumes,  cloth,  $10  00;  leather,  $12  00. 
This  great  work  is  now  recognized  in  England  as  the  fullest  and  most  authoritative  treatise  on 
every  department  of  its  important  subject.     In  laying  it,  in  its  improved  form,  before  the  Ameri- 
can profession,  the  publisher  trusts  that  it  will  assume  the  same  position  in  this  country. 


Henry  C.  Lea's  Publications — {Psychological  Medicine^  &g.).      31 


rPOKE  {DANIEL  HACK),  M.D., 

-*■  Joint  atithor  of  "  The  Manual  of  Psychological  3fedicine,"  d-c. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN   HEALTH  AND  DISEASE.      Designed  to  illustrate  the  Action  of  toe 
Imagination.     In  one  handsome  octavo  volume  of  416  pages,  extra  cloth,  $3  25.     (Now 
Ready.) 
The  object  of  the  author  in  this  work  has  been  to  show  not  only  the  effect  of  the  mind  in  caus- 
ing and  intensifying  disease,  but  also  its  curative  influence,  and  the  use  which  may  be  made  of 
the  imagination  and  the  emotions  as  therapeutic  agents.     Scattered  facts  bearing  upon  this  sub- 
ject have  long  been  familiar  to  the  profession,  but  no  attempt  has  hitherto  been  made  to  collect 
and  systematize  them  so  as  to  render  them  available  to  the  practitioner,  by  establishing  the  seve- 
ral phenomena  up^n  a  scientific  basis.     In  the  endeavor  thus  to  convert  to  the  use  of  legitimate 
medicine  the  means  which  have  been  employed  so  successfully  in  many  systems  of  quackery,  the 
author  has  produced  a  work  of  the  highest  freshness  and  interest  as  well  as  of  permanent  value. 


DLANDFORD  (G.  FIELDING),  M.  D.,  F.  R.C  P., 

J-^  Lecturer  on  Psychological  Medicine  at  the  School  of  St.  George's  Hospital,  Sec. 

INSANITY  AND  ITS  TREATMENT:  Lectures  on  the  Treatment, 

Medical  and   Legal,  of  Insane  Patients.     With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on  the  Confinement  of  the  Insane.     By  Isaac  Ray,  M.  D.     In  one  very 
handsome  octavo  volume  of  471  pages:  extra  cloth,  $3  25.     {Jiist  Issued.) 
This  volume  is  presented  to  meet  the  want,  so  frequently  expressed,  of  a  comprehensive  trea- 
tise, in  moderate  compass,  on  the  pathology,  diagnosis,  and  treatment  of  insanity.    To  render  it  of 
more  value  to  the  practitioner  in  this  country,  Dr.  Ray  has  added  an  appendix  which  affords  in- 
formation, not  elsewhere  to  be  found  in  so  accessible  a  form,  to  physicians  who  may  at  any  moment 
be  called  upon  to  take  action  in  relation  to  patients. 


It  satisfies  a  want  which  must  have  beeu  sorely 
felt  by  the  busy  general  practitioners  of  this  country. 
It  takes  the  form  of  a  manual  of  clinical  description 
of  th«  various  forms  of  insanity,  with  a  description 
of  the  mode  of  examiniog  persons  suspected  of  in- 
sanity. We  call  particular  attention  to  this  feature 
of  the  book,  as  giving  it  a  unique  value  to  the  gene- 
ral practitioner.  If  we  pass  from  theoretical  conside- 
rations to  descriptions  of  the  varieties  of  insanity  as 


actually  seen  in  practice  and  the  appropriate  treat- 
ment for  them,  we  find  in  Dr.  Blandford's  w<irk  a 
considerable  advance  over  previous  writings  on  the 
subject.  His  pictures  of  the  various  forms  of  mental 
disease  are  so  clear  and  good  that  no  reader  can  fail 
to  be  struck  with  their  superiority  to  those  given  in 
ordinary  manuals  in  the  English  language  or  (so  far 
as  our  own  reading  extends;  in  any  other. — London 
Practitioner,  Feb.  1871. 


W: 


INSLOW  {FORBES),  M.D.,  D.C.L.,  ^c. 

ON  OBSCURE  DISEASES  OF  THE  BRAIN  AND  DISORDERS 

OF  THE  MIND;  their  incipient  Symptoms,  Pathology,  Diagnosis,  Treatment,  and  Pro- 
phylaxis. Second  American,  from  the  third  and  revised  English  edition.  In  one  handsome 
octavo  volume  of  nearly  600  pages,  extra  cloth.     $4  25. 

T  EA  {HENRY  C). 

SUPERSTITION    AND    FORCE:    ESSAYS    ON    THE   WAGER   OF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.  Second  Edition, 
Enlarged.  In  one  handsome  volume  royal  12mo.  of  nearly  600  pages  j  extra  cloth,  $2  76. 
(Lately  Published.) 

We  know  of  no  single  work  which  contains,  in  so  i  interesting  phases  of  human  society  and  progress.  . 
small  a  compass,  so  much  illusiraiive  of  thestrangest     The  fulness  and  breadth  with  which  he  has  carried 


operations  of  the  human  miud.  Foot-notes  give  the 
authority  for  each  statement,  showing  vast  research 
and  wonderful  industry.  We  advise  our  confreres 
to  read  this  book  and  ponder  its  teachings. — Chicago 
Mfd.  Journal,  Aug.  1S70. 

As  a  work  of  curious  inquiry  on  certain  outlying 
points  of  obsolete  law,  "Superstition  and  Force"  is 
one  of  the  most  remarkable  books  we  have  met  with. 
— London  Athetiaam,  Nov.  3,  18ti6. 

He  has  thrown  a  great  deal  of  light  upon  what  must 
be  regarded  as  one  of  the  most  instructive  as  well  as 


out  his  comparative  survey  of  this  repulsive  field  of 
history  [Torture],  are  such  as  to  preclude  our  duing 
justice  to  the  work  within  our  present  limits.  But 
here,  as  throughout  the  volume,  there  will  be  found 
a  wealth  of  iUuslratiun  and  a  critical  grasp  of  the 
philosophical  import  of  facts  which  will  render  Mi. 
Lea's  labors  of  sterling  value  to  the  historical  stu- 
dent.— London  Saturday  Review,  Oct.  S,  1870. 

As  a  book  of  ready  reference  on  the  subject,  it  is  of 
the  highest  value. — Westminster  Review,  Oct.  1867. 


B 


J  THE  SAME  AUTHOR.     [Late  y  Published.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF  THE  TEM- 
PORAL POWER— BENEFIT  OF  CLERGY— EXCOMMUNICATION.  In  one  large  royal 
12mo.  volume  of  516  pp.  extra  cloth.     $2  75. 


The  story  was  never  told  more  calmly  or  with 
greater  learning  or  wiser  thought.  We  doubt,  indeed, 
if  auy  other  study  of  this  field  can  be  compared  with 
this  for  clearness,  accuracy,  and  power. —  Chicago 
Examiner,  Dec.  1870. 

Mr.  Lea's  latest  work,  "Studies  inChurch  History," 
fully  sustains  the  promise  of  the  first.  It  deals  with 
three  subjects — the  Temporal  Power,  Benefit  of 
Clergy,  and  Excommunication,  the  record  of  which 
ha.s  a  peculiar  importance  fur  the  English  student,  and 
Is  a  chapter  on  Ancient  Law  likely  to  be  regarded  as 
final.  We  can  hardly  pass  from  our  mention  of  such 
works  as  these — with  which  that  on  "Sacerdotal 
Celibacy"'  shonld  be  included — without  noting  the 


literary  phenomenon  that  the  head  of  one  of  the  first 
American  houses  is  also  the  writer  of  some  of  its  most 
original  books. — London  Athenceum,  Jan.  7,  1871. 

Mr.  Lea  has  doue  great  honor  to  himself  and  this 
country  by  the  admirable  works  he  has  written  on 
ecclesiologicaland  cognate  subjects.  We  have  already 
had  occasion  to  commend  his  "Superstition  and 
Force"  and  his  "History  of  Sacerdotal  Celibacy." 
The  present  volume  is  fully  as  admirable  in  its  me- 
thod of  dealing  with  topics  and  ia  the  thoroughness — 
a  quality  so  frequently  lacking  in  American  authors — 
with  which  they  are  luvestigated. — N.  Y.  Journal  of 
Psychol  Medicine,  July,  1S70. 


32 


Henry  C.  Lea's  PuBLICATTO^  s. 


INDEX    TO    CATALOGUE. 


Amfcrican  Joarnal  of  the  Medical  Sciences 
American  Chemist  (The)         .... 
Ab.'itract,  Half-Yearly,  of  the  Med   Sciences 
Anatomical  Atlas,  by  Smith  and  Horner 
Anderson  on  Diseases  of  ihe  Skiu 
Ashton  on  the  Rectum  and  Anus  . 
Attfieid's  Chemistry      .... 
Ashwell  on  Diseases  of  Females  . 
Ashhurst's  Surgery  .... 

Barnes  on  Diseases  of  Women 
Bellamy's  Surgical  Anatomy 
Bryant's  Practical  Surgery     . 
Bloxam's  Chemistry        •         .         .        . 
Blandford  on  Insanity     .... 
Basham  on  Renal  Diseases 
Briuton  on  the  Stomach 
Bigelow  on  the  Hip  .... 

Barlow's  Practice  of  Medicine 
Bowman's  (John  E.)  Practical  Chemistry 
Bowman's  (John  E.)  Medical  Chemistry 
Buckler  on  Bronchitis  .... 
liamstead  on  Venereal  .... 
Bamstead  and  Cullerier's  Atlas  of  Venereal 
Carpenter's  Human  Physiology  . 
Carpenter's  Comparative  Physiology  . 
Carpenter  on  the  Use  and  Abuse  of  Alcohol 
Carson's  Synopsis  of  Materia  Medica  . 
Chambers  on  the  Indigestions 
Chambers's  Restorative  Medicine 
Christison  and  Griffith's  Dispensatory 
Churchill's  System  of  Midwifery  . 
Churchill  on  Puerperal  Fever 
Condie  on  Diseases  of  Children 
Cooper's  (B.  B  )  Lectures  on  Surgery  . 
Cullerier's  Atlas  of  Venereal  Diseases 
Cyclopedia  of  Practical  Medicine  . 
Dalton's  Human  Physiology  . 
De  Jongh  on  Cod-Liver  Oil  . 
Dewees's  System  of  Midwifery 
Dewees  on  Diseases  of  Females  . 
De  wees  on  Diseases  of  Children  . 
Druitt's  Modern  Surgery 
Dunglison's  Medical  Dictionary  . 
Dunglison's  Human  Physiology  . 
Duuglison  on  New  Remedies 
Ellis's  Medical  Formulary,  by  Smith  . 
Erichsen's  System  of  Surgery 
Fenwick's  Diagnosis  .... 
Flint  on  Respiratory  Organs  . 

Flint  on  the  Heart 

Flint's  Practice  of  Medicine   . 
Fownes's  Elementary  Chemistry  . 
Fox  on  Diseases  of  the  Stomach     . 
Fuller  on   the  Lungs,  &c. 
Green's  Pathology  and  Morhid  Anatomy 

Gibson's  Surgery 

G  luge's  Pathological  Histology,  by  Leidy 
Galloway's  Qualitative  Analy.sis  . 

Gray's  Anatomy 

Griffith's  (R.  E.)  Universal  Formulary 
Gross  on  Foreign  Bodies  in  Air-Passages 
Gross's  Principles  and  Practice  of  Surgery  , 
Gross's  Pathological  Anatomy 
Guersant  on  Surgical  Diseases  of  Children 
Hamilton  on  Dislocations  and  Fractures 
Hartshorne's  Essentials  of  Medicine 
Hartshorne's  Conspectus  of  the  Medical  Scie 
Hartshorne's  Anatomy  and  Physiology 
Heath's  Practical  Anaiomy    . 
Hoblyn's  Medical  Dictionary 

Hodge  on  Women 

Budge's  Obstetrics 

Hodges'  Practical  Dissections 

Holland's  Medical  Notes  and  Reflections 

Horner's  Anatomy  and  Histology 

Hudson  on  Fevers  .... 

Hill  on  Venereal  Diseases 

Hillier's  Handbook  of  Skin  Diseases 

Jones  and  Sieveking's  Pathological  Anatomy 


PAGE 

1 
11 

3 

6 
20 
28 
10 
2.S 
27 
23 

7 
29 
10 
31 
18 
16 
28 
14 
11 
11 
17 
19 
19 


Jones  (C.  Handfield)  on  Nervous  Disorders 

Kirkes'  Physiology 

Knapp's  Chemical  Technology 

Lea's  Superstition  and  Force 

Lea's  Studies  in  Church  History    . 

Lincoln  on  Electro  Therapeutics     . 

Leishmau's  Midwifery     .... 

La  Roche  on  Yellow  Fever     . 

La  Roche  on  Pneumonia,  &c. 

Laurence  and  Moon's  Ophthalmic  Surgei'y 

Lawson  on  the  Eye  .... 

Laycock  on  Medical  Observation  . 

Lehmann's  Physiological  Chemistry,  2  vols. 

Lehmann's  Chemical  Physiology  . 

Ludlow's  Manual  of  Examinations 

Lyons  on  Fever 

Maclise's  Surgical  Anatomy  . 

Marshall's  Physiology    .... 

Medical  News  and  Library     . 

Meigs's  Lectures  on  Diseases  of  Women 

Meigs  on  Puerperal  Fever 

Miller's  Practice  of  Surgery  . 

Miller's  Principles  of  Surgery 

Montgomery  on  Pregnancy    . 

Neill  and  Smith's  Compendium  of  Med.  Science  . 

Neligan's  Atlas  of  Diseases  of  the  Skin 

Neligan  on  Diseases  of  the  Skin 

Obstetrical  Journal 

Odling's  Practical  Chemistry 

Pavy  on  Digestion 

Pavy  on  Food  .... 

Prize  Essays  on  Consumption 

Parrish's  Practical  Pharmacy 

Pirrie's  System  of  Surgery 

Pereira's  Mat.  Medica  and  Therapeutics,  abrid 

Quain  and  Sharpey's  Anatomy,  by  Leidy 

Roberts  on  Urinary  Diseases  . 

Ramsbotham  on  Parturition  . 

Rigby's  Midwifery 

Royle's  Materia  Medica  and  Therapeutics 

Swayne's  Obstetric  Aphorisms 

Sargent's  Minor  Surgery 

Sharpey  and  Quain's  Anatomy,  by  Leidy 

Skey's  Operative  Surgery 

Slade  on  Diphtheria        .... 

Smith  (J.  L.)  on  Children 

Smith  (H.  H.)  and  Horner's  Anatomical  Atla 

Smith  (Edward)  on  Consumption  . 

Smith  on  Wasting  Diseases  of  Children 

Still6's  Therapeutics        .... 

Sturges  on  Clinical  Medicine 

Tanner's  Manual  of  Clinical  Medicine  . 

Tanner  on  Pregnancy     .... 

Taylor's  Medical  Jurisprudence 

Taylor's  Principles  and  Practice  of  Med    Jurisp. 

Tuke  on  the  Influence  of  the  Mind 

Thomas  on  Diseases  of  Females     . 

Thompson  on  Urinary  Organs 

Thompson  on  Stricture    .... 

Thompson  on  the  Pro.state 

Todd  on  Acute  Diseases  ... 

Wales  on  Surgical  Operations 

Walshe  on  the  Heart      .... 

Watson's  Practice  of  Physic  . 

Wells  on  the  Eye 

West  on  Diseases  of  Females 

West  on  Diseases  of  Children 

West  on  Nervous  Disorders  of  Children 

West  on  Ulceration  of  Os  Uteri 

What  to  Observe  in  Medical  Cases 

Williams  on  Consumption 

Wilson  s  Human  Anatomy     . 

Wilson  on  Diseases  of  the  Skin 

Wilson's  Hates  on  Diseases  of  the  Skin 

Wilson's  Handbook  of  Cutaneous  Medicine 

Winslow  on  Brain  and  Wind 

Wohler's  Organic  Chemistry 

Winckel  on  Childbed 

Zeissl  on  Venereal  . 


For  "The  American  Chemist"  Five  Dollars  a  year,  see  p.  11. 
P'or  "The  Obstetrical  Journal"  Five  Dollars  a  year,  see  p.  22. 


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